Provider Demographics
NPI:1043401508
Name:CORRALES FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:CORRALES FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALYSON
Authorized Official - Middle Name:P
Authorized Official - Last Name:THAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-792-3065
Mailing Address - Street 1:3841 CORRALES RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-9311
Mailing Address - Country:US
Mailing Address - Phone:505-792-3065
Mailing Address - Fax:505-792-4004
Practice Address - Street 1:3841 CORRALES RD
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-9311
Practice Address - Country:US
Practice Address - Phone:505-792-3065
Practice Address - Fax:505-792-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34224801Medicaid
NM34224801Medicaid