Basic Information
| Provider Information | |||||||||
| NPI: | 1740748607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRIES | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6028 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956046028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308785166 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 159 BRENTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959455703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302711140 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2019 | ||||||||
| LastUpdateDate: | 03/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 164012 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.