Provider Demographics
NPI:1316783715
Name:LAZUR, KORY JAYDEN (ATC)
Entity type:Individual
Prefix:
First Name:KORY
Middle Name:JAYDEN
Last Name:LAZUR
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 JOHNSTON AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-3207
Mailing Address - Country:US
Mailing Address - Phone:860-917-7950
Mailing Address - Fax:
Practice Address - Street 1:70 LOVELAND HILL RD
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-6836
Practice Address - Country:US
Practice Address - Phone:860-870-6314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-04
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT20000562962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer