Provider Demographics
NPI:1356896369
Name:GRACE, COREY
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:GRACE
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 1:1802 GALLOWAY ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-3467
Mailing Address - Country:US
Mailing Address - Phone:715-831-8966
Mailing Address - Fax:
Practice Address - Street 1:1820 2ND AVE SE STE 360
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-4155
Practice Address - Country:US
Practice Address - Phone:763-689-3226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2016-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist