Provider Demographics
NPI:1326490038
Name:MARTIN, CORY
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:MARTIN
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 1:309 W CARMAN RD
Mailing Address - Street 2:
Mailing Address - City:EL DORADO SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64744-2218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 W CARMAN RD
Practice Address - Street 2:
Practice Address - City:EL DORADO SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64744-2218
Practice Address - Country:US
Practice Address - Phone:417-296-1192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORCB-683173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist