Healthcare Provider Details

I. General information

NPI: 1831833573
Provider Name (Legal Business Name): CORI KRESGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 ROUTE 25A
MILLER PLACE NY
11764-2514
US

IV. Provider business mailing address

464 ROUTE 25A
MILLER PLACE NY
11764-2514
US

V. Phone/Fax

Practice location:
  • Phone: 631-680-9458
  • Fax:
Mailing address:
  • Phone: 631-680-9458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number032941
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: