Provider Demographics
NPI:1891312427
Name:THREATT, CORY (LDO)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:THREATT
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 CHERRY RD S STE 120
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-3413
Mailing Address - Country:US
Mailing Address - Phone:803-366-3937
Mailing Address - Fax:803-366-3967
Practice Address - Street 1:232 CHERRY RD S STE 120
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3413
Practice Address - Country:US
Practice Address - Phone:803-366-3937
Practice Address - Fax:803-366-3967
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC740156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician