Provider Demographics
NPI:1538708011
Name:CORYELL, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:CORYELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85203 JASPER PARK RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:OR
Mailing Address - Zip Code:97455-9773
Mailing Address - Country:US
Mailing Address - Phone:541-852-8806
Mailing Address - Fax:
Practice Address - Street 1:85203 JASPER PARK RD
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:OR
Practice Address - Zip Code:97455-9773
Practice Address - Country:US
Practice Address - Phone:541-852-8806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34713111N00000X
OR6121111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor