Healthcare Provider Details

I. General information

NPI: 1316587538
Provider Name (Legal Business Name): MAKENZIE L CORK ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W COOPER ST
STERLING KS
67579-2500
US

IV. Provider business mailing address

125 W COOPER ST
STERLING KS
67579-2500
US

V. Phone/Fax

Practice location:
  • Phone: 620-278-6178
  • Fax:
Mailing address:
  • Phone: 620-278-6178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number24-01371
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: