Provider Demographics
NPI:1407587975
Name:DAVIS, CORY SCOTT (HIS)
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:SCOTT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:CORY
Other - Middle Name:S
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CORY DAVIS HIS
Mailing Address - Street 1:4337 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-7806
Mailing Address - Country:US
Mailing Address - Phone:219-809-0291
Mailing Address - Fax:
Practice Address - Street 1:4337 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7806
Practice Address - Country:US
Practice Address - Phone:219-809-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001557A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist