Provider Demographics
NPI:1790422178
Name:RALEY, CORBEN MICHAEL PHILIP
Entity Type:Individual
Prefix:
First Name:CORBEN
Middle Name:MICHAEL PHILIP
Last Name:RALEY
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 1:1400 N NORMA ST STE 131
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-2577
Mailing Address - Country:US
Mailing Address - Phone:760-463-5059
Mailing Address - Fax:760-499-9259
Practice Address - Street 1:1400 N NORMA ST STE 131
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-2577
Practice Address - Country:US
Practice Address - Phone:760-463-5059
Practice Address - Fax:760-499-9259
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist