Healthcare Provider Details

I. General information

NPI: 1508137852
Provider Name (Legal Business Name): CORINA J BEJARANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E MESCALERO RD
ROSWELL NM
88201-6542
US

IV. Provider business mailing address

PO BOX 1978
ROSWELL NM
88202-1978
US

V. Phone/Fax

Practice location:
  • Phone: 575-623-1480
  • Fax: 575-622-3325
Mailing address:
  • Phone: 575-623-1480
  • Fax: 575-622-3325

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: