Healthcare Provider Details

I. General information

NPI: 1043401508
Provider Name (Legal Business Name): CORRALES FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3841 CORRALES RD
CORRALES NM
87048-9311
US

IV. Provider business mailing address

3841 CORRALES RD
CORRALES NM
87048-9311
US

V. Phone/Fax

Practice location:
  • Phone: 505-792-3065
  • Fax: 505-792-4004
Mailing address:
  • Phone: 505-792-3065
  • Fax: 505-792-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number86346
License Number StateNM

VIII. Authorized Official

Name: MS. ALYSON P THAL
Title or Position: OWNER
Credential: M.D.
Phone: 505-792-3065