Provider Demographics
NPI:1992457162
Name:KORIE MEDICAL CORPORATION DBA SOUL KLINIC
Entity type:Organization
Organization Name:KORIE MEDICAL CORPORATION DBA SOUL KLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IJENDU
Authorized Official - Middle Name:
Authorized Official - Last Name:KORIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-506-0607
Mailing Address - Street 1:25050 PEACHLAND AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2523
Mailing Address - Country:US
Mailing Address - Phone:661-506-0607
Mailing Address - Fax:
Practice Address - Street 1:25050 PEACHLAND AVE STE 170
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91321-2523
Practice Address - Country:US
Practice Address - Phone:661-506-0607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-19
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty