Healthcare Provider Details

I. General information

NPI: 1194213736
Provider Name (Legal Business Name): DONALD ROBERT FRAGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 S ATKINSON AVE
ROSWELL NM
88203-7154
US

IV. Provider business mailing address

704 GROVE ST
ROSWELL NM
88201-7434
US

V. Phone/Fax

Practice location:
  • Phone: 575-578-4826
  • Fax:
Mailing address:
  • Phone: 575-420-6466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number0180371
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: