Healthcare Provider Details

I. General information

NPI: 1447525316
Provider Name (Legal Business Name): COREY H TABBERT OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2012
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 NE 5TH ST
GRAND RAPIDS MN
55744-2760
US

IV. Provider business mailing address

15 NE 5TH ST
GRAND RAPIDS MN
55744-2760
US

V. Phone/Fax

Practice location:
  • Phone: 218-327-1148
  • Fax:
Mailing address:
  • Phone: 218-327-1148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2883
License Number StateMN

VIII. Authorized Official

Name: DR. COREY TABBERT
Title or Position: OWNER
Credential: OD
Phone: 218-327-1148