Healthcare Provider Details

I. General information

NPI: 1275809709
Provider Name (Legal Business Name): BRADY W CORSE ATC/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NE MOTHER JOSEPH PLACE SUITE 100
VANCOUVER WA
98664
US

IV. Provider business mailing address

200 NE MOTHER JOSEPH PLACE SUITE 100
VANCOUVER WA
98664
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-2048
  • Fax:
Mailing address:
  • Phone: 360-514-2048
  • Fax: 360-514-5033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number60068895
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: