Healthcare Provider Details

I. General information

NPI: 1124755756
Provider Name (Legal Business Name): CORNELIUS R MACKEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4706 LEON GRANDE AVE SE
RIO RANCHO NM
87124-1303
US

IV. Provider business mailing address

202 11TH AVE NW
RIO RANCHO NM
87144-4164
US

V. Phone/Fax

Practice location:
  • Phone: 505-934-4431
  • Fax:
Mailing address:
  • Phone: 505-934-4431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: