Healthcare Provider Details

I. General information

NPI: 1902310022
Provider Name (Legal Business Name): COREY A CARTER S.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E 19TH STREET
ROSWELL NM
88201
US

IV. Provider business mailing address

117 E 19TH ST
ROSWELL NM
88201-5151
US

V. Phone/Fax

Practice location:
  • Phone: 575-627-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: