1144349135 NPI number — CORY FURY BRAINARD OT

Table of content: CORY FURY BRAINARD OT (NPI 1144349135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144349135 NPI number — CORY FURY BRAINARD OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAINARD
Provider First Name:
CORY
Provider Middle Name:
FURY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FURY
Provider Other First Name:
CORY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1144349135
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15465 OAK LANE SUITE 100 C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULFPORT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39503-2663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-615-2493
Provider Business Mailing Address Fax Number:
228-265-8323

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15465 OAK LANE SUITE 100 C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39503-2663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-615-2493
Provider Business Practice Location Address Fax Number:
228-265-8323
Provider Enumeration Date:
03/28/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  Z10511 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: OT-1903 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)