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General NPI Number Information
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NPI Number | 1922185644
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Entity Type | Organization
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Legal Business Name | TRI STATE SPORTS MEDICINE AND REHABILITATION INC
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 08/30/2018
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Provider Practice Location Address
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Address Line | 2255 HIGHWAY 25E STE 4
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City | TAZEWELL
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State | TN
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Zip | 37879
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Country | US
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Telephone | 423-626-7848
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Fax | 423-626-7849
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Provider Business Mailing Address
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Address Line | PO BOX 1310
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City | POWELL
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State | TN
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Zip | 37849-1310
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Country | US
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Telephone | 865-805-1218
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Fax | 423-626-7849
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Authorized Official
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Title or Position | OWNER
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Name | DALE RICHARD CORUM
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Credential |
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Telephone | 423-626-7848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 3108
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License Number State | TN
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