Provider Demographics
NPI:1093812711
Name:COUILLARD, CORY DEAN (DC, ATC)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:DEAN
Last Name:COUILLARD
Suffix:
Gender:M
Credentials:DC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20176 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6855
Mailing Address - Country:US
Mailing Address - Phone:952-594-2796
Mailing Address - Fax:952-469-1713
Practice Address - Street 1:20176 HERITAGE DR
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6855
Practice Address - Country:US
Practice Address - Phone:952-594-2796
Practice Address - Fax:952-469-1713
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4869111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor