Provider Demographics
NPI:1881320398
Name:GRAHAM, COREY BERNARD SR
Entity type:Individual
Prefix:MR
First Name:COREY
Middle Name:BERNARD
Last Name:GRAHAM
Suffix:SR
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 1:850 PALM BLVD
Mailing Address - Street 2:
Mailing Address - City:PAHOKEE
Mailing Address - State:FL
Mailing Address - Zip Code:33476-2519
Mailing Address - Country:US
Mailing Address - Phone:561-723-1150
Mailing Address - Fax:
Practice Address - Street 1:850 PALM BLVD
Practice Address - Street 2:
Practice Address - City:PAHOKEE
Practice Address - State:FL
Practice Address - Zip Code:33476-2519
Practice Address - Country:US
Practice Address - Phone:561-723-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL082956667OtherDUNN NUMBER