Provider Demographics
NPI:1598557308
Name:BROUGHTON, KORY WILLIAM
Entity type:Individual
Prefix:
First Name:KORY
Middle Name:WILLIAM
Last Name:BROUGHTON
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 1:210 E 181ST ST APT 6M
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-2149
Mailing Address - Country:US
Mailing Address - Phone:347-255-9762
Mailing Address - Fax:
Practice Address - Street 1:1 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5802
Practice Address - Country:US
Practice Address - Phone:212-254-7722
Practice Address - Fax:646-548-8976
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033032172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172M00000XOther Service ProvidersMechanotherapistGroup - Single Specialty