Healthcare Provider Details

I. General information

NPI: 1184080731
Provider Name (Legal Business Name): COR MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5828 MANGO DR
SAINT LOUIS MO
63129-2243
US

IV. Provider business mailing address

5828 MANGO DR
SAINT LOUIS MO
63129-2243
US

V. Phone/Fax

Practice location:
  • Phone: 314-701-4664
  • Fax:
Mailing address:
  • Phone: 314-701-4664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: KERRY JOE JAMES
Title or Position: MANAGER
Credential: SA-C
Phone: 314-392-3998