Healthcare Provider Details

I. General information

NPI: 1801128111
Provider Name (Legal Business Name): DOUG MCCORKLE PT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 02/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 CANOE BROOK RD
E DUMMERSTON VT
05346-9770
US

IV. Provider business mailing address

247 CANOE BROOK RD
E DUMMERSTON VT
05346-9770
US

V. Phone/Fax

Practice location:
  • Phone: 802-387-3025
  • Fax: 802-387-3025
Mailing address:
  • Phone: 802-387-3025
  • Fax: 802-387-3025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number040-0003309
License Number StateVT

VIII. Authorized Official

Name: MR. DOUGLAS R MCCORKLE
Title or Position: OWNER
Credential: PT
Phone: 802-387-3025