Provider Demographics
NPI:1477012490
Name:MCCORKLE, DARIS
Entity Type:Individual
Prefix:
First Name:DARIS
Middle Name:
Last Name:MCCORKLE
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:PO BOX 926
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70704-0926
Mailing Address - Country:US
Mailing Address - Phone:504-931-9962
Mailing Address - Fax:
Practice Address - Street 1:810 CHIPLEY ST
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-4314
Practice Address - Country:US
Practice Address - Phone:504-931-9962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver