Healthcare Provider Details

I. General information

NPI: 1922051945
Provider Name (Legal Business Name): MATTHEW CORN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1978 TAMIAMI TRL S SUITES 5 & 6
VENICE FL
34293-5006
US

IV. Provider business mailing address

1331 WHISPERING LN
VENICE FL
34285-6449
US

V. Phone/Fax

Practice location:
  • Phone: 941-451-6607
  • Fax: 941-451-2028
Mailing address:
  • Phone: 941-451-6607
  • Fax: 941-451-2028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number21464
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT21464
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: