Healthcare Provider Details

I. General information

NPI: 1871820977
Provider Name (Legal Business Name): MARCIA ALLEN BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2009
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5011 MONTGOMERY BLVD NE SUITE B2
ALBUQUERQUE NM
87109-1350
US

IV. Provider business mailing address

5011 MONTGOMERY BLVD NE SUITE B2
ALBUQUERQUE NM
87109-1350
US

V. Phone/Fax

Practice location:
  • Phone: 505-872-3668
  • Fax: 505-888-7041
Mailing address:
  • Phone: 505-872-3668
  • Fax: 505-888-7041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number202635927
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: