Basic Information
| Provider Information | |||||||||
| NPI: | 1518973163 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHRISTENSEN | ||||||||
| FirstName: | COREY | ||||||||
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| Credential: | PT, MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2445 MISSOURI AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880015111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755238080 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2445 MISSOURI AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880015111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755238080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 06/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 3238 | NM | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | QMYPR0070685 | 01 | NM | MOLINA HEALTH PLAN | OTHER | 88286002 | 05 | NM | MEDICAID | NM00Q560 | 01 | NM | BLUE CROSS BLUE SHIELD | OTHER |