Provider Demographics
NPI:1336433184
Name:KORELL, KHRISTOPHER EDWARD
Entity Type:Individual
Prefix:
First Name:KHRISTOPHER
Middle Name:EDWARD
Last Name:KORELL
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 1:1159 E IRON EAGLE DR ST 170
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6871
Mailing Address - Country:US
Mailing Address - Phone:208-514-0670
Mailing Address - Fax:208-549-7880
Practice Address - Street 1:2635 CALDWELL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-6407
Practice Address - Country:US
Practice Address - Phone:208-442-0577
Practice Address - Fax:208-442-7455
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2871225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1652931Medicare PIN