Healthcare Provider Details

I. General information

NPI: 1396393096
Provider Name (Legal Business Name): CASSANDRA CORIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 CERRILLOS RD
SANTA FE NM
87505-3521
US

IV. Provider business mailing address

PO BOX 727
SANTO DOMINGO PUEBLO NM
87052-0727
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT732
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: