=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508554528
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORY HARDIN CO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2023
-----------------------------------------------------
Last Update Date | 04/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1481 W 10TH ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46202-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-988-3722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2519 RAINBOW DR
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47904-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-513-1209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 222Z00000X
-----------------------------------------------------
Taxonomy Name | Orthotist
-----------------------------------------------------
License Number | CO005517
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------