Provider Demographics
NPI:1124040688
Name:OSBORNE, COREY ALAN (DC)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:ALAN
Last Name:OSBORNE
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 1:734 CAMBRIDGE BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1964
Mailing Address - Country:US
Mailing Address - Phone:618-622-9780
Mailing Address - Fax:618-622-9782
Practice Address - Street 1:734 CAMBRIDGE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1964
Practice Address - Country:US
Practice Address - Phone:618-622-9780
Practice Address - Fax:618-622-9782
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03227051OtherBC/BS
ILK17312Medicare ID - Type Unspecified