Provider Demographics
NPI:1396489795
Name:COREY, S. ANGELINE
Entity type:Individual
Prefix:
First Name:S. ANGELINE
Middle Name:
Last Name:COREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 N RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-6024
Mailing Address - Country:US
Mailing Address - Phone:541-613-8241
Mailing Address - Fax:
Practice Address - Street 1:16 N RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-6024
Practice Address - Country:US
Practice Address - Phone:541-613-8241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22618225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist