Provider Demographics
NPI:1376759050
Name:PACK, CORY BLAINE (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:BLAINE
Last Name:PACK
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6018 VAN DORN DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-2829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3410 TAFT BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2036
Practice Address - Country:US
Practice Address - Phone:940-397-4824
Practice Address - Fax:940-397-4901
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT18042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer