Healthcare Provider Details

I. General information

NPI: 1144534892
Provider Name (Legal Business Name): KATHRYN BRANCH CASEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 STATE ROAD 1
SOCORRO NM
87801-5004
US

IV. Provider business mailing address

1101 STATE RD 1 SW
SOCORRO NM
87801
US

V. Phone/Fax

Practice location:
  • Phone: 575-835-2234
  • Fax:
Mailing address:
  • Phone: 575-835-2234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: