Healthcare Provider Details

I. General information

NPI: 1376512467
Provider Name (Legal Business Name): PATRICE MICHELLE CORDERO D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N MAIN ST
FORT STOCKTON TX
79735-5627
US

IV. Provider business mailing address

PO BOX 1605
FORT STOCKTON TX
79735-1605
US

V. Phone/Fax

Practice location:
  • Phone: 432-336-3909
  • Fax: 432-336-6677
Mailing address:
  • Phone: 432-336-3909
  • Fax: 432-336-6677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6147
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: