Healthcare Provider Details

I. General information

NPI: 1003481235
Provider Name (Legal Business Name): CORY RAISOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SUNSET HILLS DR
MACON MO
63552-2165
US

IV. Provider business mailing address

703 W LEE ST
DIMMITT TX
79027-3117
US

V. Phone/Fax

Practice location:
  • Phone: 660-385-3113
  • Fax:
Mailing address:
  • Phone: 435-749-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2156885
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: