Provider Demographics
NPI:1619309705
Name:TILDEN, CORY J (ATC, AT)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:J
Last Name:TILDEN
Suffix:
Gender:M
Credentials:ATC, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6270 ROSELAWN AVE
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-1720
Mailing Address - Country:US
Mailing Address - Phone:330-285-2351
Mailing Address - Fax:
Practice Address - Street 1:6270 ROSELAWN AVE
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-1720
Practice Address - Country:US
Practice Address - Phone:330-285-2351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0041972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer