Provider Demographics
NPI:1306656624
Name:COLEMAN, CORY
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:COLEMAN
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 1:14164 US HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:SANDERSON
Mailing Address - State:FL
Mailing Address - Zip Code:32087-2356
Mailing Address - Country:US
Mailing Address - Phone:904-535-9302
Mailing Address - Fax:904-397-2699
Practice Address - Street 1:14164 US HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:SANDERSON
Practice Address - State:FL
Practice Address - Zip Code:32087-2356
Practice Address - Country:US
Practice Address - Phone:904-535-9302
Practice Address - Fax:904-397-2699
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6907127311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home