Healthcare Provider Details

I. General information

NPI: 1376759050
Provider Name (Legal Business Name): CORY BLAINE PACK ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 TAFT BLVD
WICHITA FALLS TX
76308-2036
US

IV. Provider business mailing address

6018 VAN DORN DR
WICHITA FALLS TX
76310-2829
US

V. Phone/Fax

Practice location:
  • Phone: 940-397-4824
  • Fax: 940-397-4901
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT1804
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: