Provider Demographics
NPI:1033755202
Name:BURT, COREY DANIEL (DC)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:DANIEL
Last Name:BURT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40175 SW LAURELWOOD RD
Mailing Address - Street 2:
Mailing Address - City:GASTON
Mailing Address - State:OR
Mailing Address - Zip Code:97119-8532
Mailing Address - Country:US
Mailing Address - Phone:503-473-2619
Mailing Address - Fax:
Practice Address - Street 1:7180 SW FIR LOOP STE 250
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8077
Practice Address - Country:US
Practice Address - Phone:503-597-8098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6029111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor