Healthcare Provider Details

I. General information

NPI: 1437755436
Provider Name (Legal Business Name): KORAH MAKAYLA ROYBAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

695 CALLE DEL SOL
BOSQUE FARMS NM
87068-9797
US

IV. Provider business mailing address

695 CALLE DEL SOL
BOSQUE FARMS NM
87068-9797
US

V. Phone/Fax

Practice location:
  • Phone: 505-916-7668
  • Fax:
Mailing address:
  • Phone: 505-916-7668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: