Basic Information
| Provider Information | |||||||||
| NPI: | 1346693736 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLWARD | ||||||||
| FirstName: | COREY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 792 GALLITZIN RD | ||||||||
| Address2: | |||||||||
| City: | CRESSON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166302213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148862955 | ||||||||
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| Practice Location | |||||||||
| Address1: | 108 FRANCISCAN WAY | ||||||||
| Address2: | |||||||||
| City: | LORETTO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159409703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144723936 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2016 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | TE010829 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1346693736 | 05 | PA | MEDICAID |