Healthcare Provider Details

I. General information

NPI: 1083345276
Provider Name (Legal Business Name): COREY MICHAEL TATE LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4326 N 35TH AVE APT 1042
PHOENIX AZ
85017-3867
US

IV. Provider business mailing address

4326 N 35TH AVE APT 1042
PHOENIX AZ
85017-3867
US

V. Phone/Fax

Practice location:
  • Phone: 623-418-4657
  • Fax:
Mailing address:
  • Phone: 623-418-4657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number28168
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: