Provider Demographics
NPI:1750678496
Name:WERITO, CORY
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:
Last Name:WERITO
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 885
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-0885
Mailing Address - Country:US
Mailing Address - Phone:505-419-4672
Mailing Address - Fax:382-729-5338
Practice Address - Street 1:NAVAJO ROUTE 12 MILE MARKER 34-3429
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504-0885
Practice Address - Country:US
Practice Address - Phone:505-419-4672
Practice Address - Fax:382-729-5338
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ343900000X343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)