Healthcare Provider Details

I. General information

NPI: 1114325966
Provider Name (Legal Business Name): IMELDA DE CORRAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2014
Last Update Date: 12/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 S SOLANO DR
LAS CRUCES NM
88001-3758
US

IV. Provider business mailing address

1505 ROBERTS DR
LAS CRUCES NM
88005-3159
US

V. Phone/Fax

Practice location:
  • Phone: 575-527-4710
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: