Provider Demographics
NPI:1912906587
Name:ALTABET, CORY H (DC)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:H
Last Name:ALTABET
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18471 SMOCK HWY
Mailing Address - Street 2:SPACE 2
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335
Mailing Address - Country:US
Mailing Address - Phone:814-337-0070
Mailing Address - Fax:814-337-0300
Practice Address - Street 1:18471 SMOCK HWY
Practice Address - Street 2:SPACE 2
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335
Practice Address - Country:US
Practice Address - Phone:814-337-0070
Practice Address - Fax:814-337-0300
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-04-07
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
PADC005204L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014846060004Medicaid
PAAL764798Medicare ID - Type Unspecified
PAU51347Medicare UPIN