Provider Demographics
NPI:1639312366
Name:ELLERBROEK, CORY R (DC)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:R
Last Name:ELLERBROEK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11420 BEE CAVES RD
Mailing Address - Street 2:A-100
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78738-5526
Mailing Address - Country:US
Mailing Address - Phone:512-263-9961
Mailing Address - Fax:512-263-9963
Practice Address - Street 1:11420 BEE CAVES RD
Practice Address - Street 2:A-100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738-5526
Practice Address - Country:US
Practice Address - Phone:512-263-9961
Practice Address - Fax:512-263-9963
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12703111N00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAJB1972002Medicare PIN