Provider Demographics
NPI:1114585163
Name:LANGBERG, CORY BRUCE
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:BRUCE
Last Name:LANGBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3212
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83877-3212
Mailing Address - Country:US
Mailing Address - Phone:208-786-2470
Mailing Address - Fax:
Practice Address - Street 1:5362 W PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5912
Practice Address - Country:US
Practice Address - Phone:208-786-2470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRCT47478171W00000X, 171WH0202X
172A00000X, 251B00000X, 347C00000X, 343900000X, 374U00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No171W00000XOther Service ProvidersContractor
No171WH0202XOther Service ProvidersContractorHome Modifications
No172A00000XOther Service ProvidersDriver
No251B00000XAgenciesCase Management
No347C00000XTransportation ServicesPrivate Vehicle
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty