Provider Demographics
NPI:1033657861
Name:CORNEJO, LUIS
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:CORNEJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 LAKE PARK AVE APT 132
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-3757
Mailing Address - Country:US
Mailing Address - Phone:209-912-8406
Mailing Address - Fax:209-375-0022
Practice Address - Street 1:1003 LAKE PARK AVE APT 132
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-3757
Practice Address - Country:US
Practice Address - Phone:209-912-8406
Practice Address - Fax:209-375-0022
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver