Healthcare Provider Details

I. General information

NPI: 1275533671
Provider Name (Legal Business Name): DALE L TRIBOUT RN, COHN-S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 HARMON AVE STE 1D03
FT STEWART GA
31314-5604
US

IV. Provider business mailing address

1061 HARMON AVE STE 1D03
FT STEWART GA
31314-5604
US

V. Phone/Fax

Practice location:
  • Phone: 912-435-5101
  • Fax: 912-435-5009
Mailing address:
  • Phone: 912-435-5101
  • Fax: 912-435-5009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License NumberRN094051
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: