Provider Demographics
NPI:1467496323
Name:LEWIS, CORY I (DPT)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:I
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2523
Mailing Address - Country:US
Mailing Address - Phone:208-457-9125
Mailing Address - Fax:
Practice Address - Street 1:740 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2523
Practice Address - Country:US
Practice Address - Phone:208-457-9125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010159647OtherREGENCE
IDT6319OtherBLUE CROSS
IDT6319OtherBLUE CROSS