Provider Demographics
NPI:1033379987
Name:CORY EYECARE PTR
Entity Type:Organization
Organization Name:CORY EYECARE PTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:P
Authorized Official - Last Name:CORY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-762-4801
Mailing Address - Street 1:6509 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3101
Mailing Address - Country:US
Mailing Address - Phone:219-762-4801
Mailing Address - Fax:219-764-9974
Practice Address - Street 1:6509 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3101
Practice Address - Country:US
Practice Address - Phone:219-762-4801
Practice Address - Fax:219-764-9974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4647860001Medicare NSC