Provider Demographics
NPI:1174257091
Name:DAVIS, CORY
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:DAVIS
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 1:3691 JENNIES CREEK RD
Mailing Address - Street 2:
Mailing Address - City:KERMIT
Mailing Address - State:WV
Mailing Address - Zip Code:25674-8099
Mailing Address - Country:US
Mailing Address - Phone:304-988-4200
Mailing Address - Fax:
Practice Address - Street 1:3691 JENNIES CREEK RD
Practice Address - Street 2:
Practice Address - City:KERMIT
Practice Address - State:WV
Practice Address - Zip Code:25674-8099
Practice Address - Country:US
Practice Address - Phone:304-988-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker