Healthcare Provider Details

I. General information

NPI: 1275969008
Provider Name (Legal Business Name): MR. BENJAMIN W. CORSEY III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 1ST ST NW
ALBUQUERQUE NM
87102-1529
US

IV. Provider business mailing address

PO BOX 25445 1217 1ST ST.
ALBUQUERQUE NM
87125-0445
US

V. Phone/Fax

Practice location:
  • Phone: 505-338-1641
  • Fax: 505-338-1646
Mailing address:
  • Phone: 505-338-1641
  • Fax: 505-338-1646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: