Healthcare Provider Details

I. General information

NPI: 1710318142
Provider Name (Legal Business Name): COREY DAVID IDROGO D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 11/28/2023
Certification Date:
Deactivation Date: 11/14/2023
Reactivation Date: 11/28/2023

III. Provider practice location address

4109 MOUNTAIN VIEW AVE SUITE 400
CHATTANOOGA TN
37415
US

IV. Provider business mailing address

4109 MOUNTAIN VIEW AVE SUITE 400
CHATTANOOGA TN
37415-2096
US

V. Phone/Fax

Practice location:
  • Phone: 423-315-1690
  • Fax: 423-777-5571
Mailing address:
  • Phone: 423-315-1690
  • Fax: 423-777-7751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038012545
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2852
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: