Healthcare Provider Details

I. General information

NPI: 1467446104
Provider Name (Legal Business Name): MR. COREY J LITTEL
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48110 SHAW RD BLDG 2187 SUITE 1240-G3
PATUXENT RIVER MD
20670-1906
US

IV. Provider business mailing address

43800 SASSAFRAS DR
CALIFORNIA MD
20619-4113
US

V. Phone/Fax

Practice location:
  • Phone: 301-342-9226
  • Fax: 301-342-8491
Mailing address:
  • Phone: 301-342-9226
  • Fax: 301-342-8491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: