Healthcare Provider Details

I. General information

NPI: 1265033286
Provider Name (Legal Business Name): COREY DILLOW LAC , LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 GREENLEAVES BLVD STE 11
MANDEVILLE LA
70448-7092
US

IV. Provider business mailing address

236 CALUMET DR
MADISONVILLE LA
70447-9110
US

V. Phone/Fax

Practice location:
  • Phone: 630-930-4035
  • Fax:
Mailing address:
  • Phone: 630-930-4035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number323918
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLA9196
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: