Provider Demographics
NPI:1366859134
Name:VANAMBERG, CORY KENNETH (ATC)
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:KENNETH
Last Name:VANAMBERG
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9524W STATE HIGHWAY M149
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854
Mailing Address - Country:US
Mailing Address - Phone:906-286-0047
Mailing Address - Fax:
Practice Address - Street 1:3 S WARWICK RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29617-6167
Practice Address - Country:US
Practice Address - Phone:906-286-0047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer