Healthcare Provider Details

I. General information

NPI: 1962015040
Provider Name (Legal Business Name): CHRISTOPHER L PEREA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 AVENIDA LAS VISTAS NW
LOS LUNAS NM
87031-8381
US

IV. Provider business mailing address

1072 AVENIDA LAS VISTAS NW
LOS LUNAS NM
87031-8381
US

V. Phone/Fax

Practice location:
  • Phone: 505-702-5359
  • Fax:
Mailing address:
  • Phone: 505-702-5359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: