Provider Demographics
NPI:1114407376
Name:POLK, DALE WAYNE
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:WAYNE
Last Name:POLK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-1496
Mailing Address - Country:US
Mailing Address - Phone:817-408-3800
Mailing Address - Fax:
Practice Address - Street 1:1300 E 2ND ST
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-1496
Practice Address - Country:US
Practice Address - Phone:817-408-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2084076225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant