=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598547689
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORY LYNN EMBRY JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2023
-----------------------------------------------------
Last Update Date | 10/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3626 OLEANDER TER
-----------------------------------------------------
City | RIVIERA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33404-1877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-524-3768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3626 OLEANDER TER
-----------------------------------------------------
City | RIVIERA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33404-1877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-524-3768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | 442448
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------