Healthcare Provider Details

I. General information

NPI: 1770363103
Provider Name (Legal Business Name): MARGUERITE ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 W APACHE TRL
APACHE JUNCTION AZ
85120-5204
US

IV. Provider business mailing address

2555 W APACHE TRL
APACHE JUNCTION AZ
85120-5204
US

V. Phone/Fax

Practice location:
  • Phone: 480-983-9557
  • Fax:
Mailing address:
  • Phone: 480-983-9557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO-002807
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: