MEDICARE: JOHN CORLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1750760088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN CORLEY

Provider Business Mailing Address
First Line	:	3832 E MAIN ST
Second Line	:	STE E
City	:	FARMINGTON
State	:	NM
Zip	:	87402-8749
Country	:	US
Telephone Number	:	505-258-4003
Fax Number	:	505-436-2740

Provider Business Practice Location Address
First Line	:	3832 E MAIN ST
Second Line	:	STE E
City	:	FARMINGTON
State	:	NM
Zip	:	87402-8749
Country	:	US
Telephone Number	:	505-258-4003
Fax Number	:	505-436-2740

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2015
Last Update Date	:	05/19/2015

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Directions to “ JOHN CORLEY ” Practice Location

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