MEDICARE: MR. ALLAN ROQUE HERNANDEZ FRUELDA PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2005012166	MO
2	225100000X	Physical Therapist	PT020108	PA

General Provider Information

NPI Number	:	1871701110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALLAN ROQUE HERNANDEZ FRUELDA PT

Provider Business Mailing Address
First Line	:	1004 PIMLICO DR
Second Line	:
City	:	EAST NORRITON
State	:	PA
Zip	:	19403-3958
Country	:	US
Telephone Number	:	417-529-8027
Fax Number	:

Provider Business Practice Location Address
First Line	:	1004 PIMLICO DR
Second Line	:
City	:	EAST NORRITON
State	:	PA
Zip	:	19403-3958
Country	:	US
Telephone Number	:	417-529-8027
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	07/10/2011

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