Provider Demographics
NPI:1457177354
Name:PICHOFF, CORY PAUL (PTA)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:PAUL
Last Name:PICHOFF
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 TYLER CIR
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:MO
Mailing Address - Zip Code:65672-5502
Mailing Address - Country:US
Mailing Address - Phone:417-598-0817
Mailing Address - Fax:
Practice Address - Street 1:16914 STATE HIGHWAY 13
Practice Address - Street 2:
Practice Address - City:REEDS SPRING
Practice Address - State:MO
Practice Address - Zip Code:65737-9670
Practice Address - Country:US
Practice Address - Phone:417-272-3909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022020026225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant