Healthcare Provider Details

I. General information

NPI: 1891751681
Provider Name (Legal Business Name): COREY EATON MED, ATC, LAT,CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 ROSS AVENUE BOX 30
DALLAS TX
75204
US

IV. Provider business mailing address

12345 ALFA ROMEO WAY
FRISCO TX
75034
US

V. Phone/Fax

Practice location:
  • Phone: 214-421-4535
  • Fax: 214-421-4778
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT1470
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: