Healthcare Provider Details

I. General information

NPI: 1427032978
Provider Name (Legal Business Name): JOSE ROBERTO CORREA M.S. CCC-A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 MAIN ST NE STE A
LOS LUNAS NM
87031-6368
US

IV. Provider business mailing address

2060 MAIN ST NE STE C
LOS LUNAS NM
87031-6368
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-4466
  • Fax:
Mailing address:
  • Phone: 505-916-5977
  • Fax: 505-916-5976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2840
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: