Provider Demographics
NPI:1497399109
Name:LIN, COREY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:LIN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13163 FOUNTAIN PARK DR APT B218
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90094-2418
Mailing Address - Country:US
Mailing Address - Phone:562-833-3508
Mailing Address - Fax:
Practice Address - Street 1:11611 SAN VICENTE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5106
Practice Address - Country:US
Practice Address - Phone:562-833-3508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2975262251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic