Provider Demographics
NPI:1750760088
Name:CORLEY, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CORLEY
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 1:3832 E MAIN ST
Mailing Address - Street 2:STE E
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-8749
Mailing Address - Country:US
Mailing Address - Phone:505-258-4003
Mailing Address - Fax:505-436-2740
Practice Address - Street 1:3832 E MAIN ST
Practice Address - Street 2:STE E
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-8749
Practice Address - Country:US
Practice Address - Phone:505-258-4003
Practice Address - Fax:505-436-2740
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant