Provider Demographics
NPI:1154898724
Name:ACOSTA, ALFREDO
Entity type:Individual
Prefix:
First Name:ALFREDO
Middle Name:
Last Name:ACOSTA
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 1:1306 W SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-4028
Mailing Address - Country:US
Mailing Address - Phone:620-253-3478
Mailing Address - Fax:
Practice Address - Street 1:1306 W SPRUCE ST
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-4028
Practice Address - Country:US
Practice Address - Phone:620-253-3478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi