Provider Demographics
NPI:1952809469
Name:FARRIS, ALAN
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:FARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3119
Mailing Address - Country:US
Mailing Address - Phone:719-251-5189
Mailing Address - Fax:
Practice Address - Street 1:117 W 6TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3119
Practice Address - Country:US
Practice Address - Phone:719-251-5189
Practice Address - Fax:719-251-5189
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0019714225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist