Healthcare Provider Details

I. General information

NPI: 1902874480
Provider Name (Legal Business Name): COREY H TABBERT OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 SE FIRST STREET
WADENA MN
56482
US

IV. Provider business mailing address

222 1ST ST SE
WADENA MN
56482-1567
US

V. Phone/Fax

Practice location:
  • Phone: 218-631-2020
  • Fax: 218-631-1892
Mailing address:
  • Phone: 218-631-2020
  • Fax: 218-631-1892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: