Provider Demographics
NPI:1487378907
Name:CORRALES, TANDY LUV
Entity type:Individual
Prefix:MS
First Name:TANDY
Middle Name:LUV
Last Name:CORRALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16808 MAIN STREET SUITE D BOX 345
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345
Mailing Address - Country:US
Mailing Address - Phone:760-221-2421
Mailing Address - Fax:760-888-3575
Practice Address - Street 1:17096 SEQUOIA ST STE 116
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1411
Practice Address - Country:US
Practice Address - Phone:760-985-7765
Practice Address - Fax:760-888-3575
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver