Healthcare Provider Details

I. General information

NPI: 1639880388
Provider Name (Legal Business Name): CARLI D. CORPUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2022
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2036 NE WILLIAMSON CT
BEND OR
97701-3771
US

IV. Provider business mailing address

2245 W TRESTLE DR
MERIDIAN ID
83646-1593
US

V. Phone/Fax

Practice location:
  • Phone: 541-706-6348
  • Fax:
Mailing address:
  • Phone: 208-994-1549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: