Provider Demographics
NPI:1134504764
Name:EAST TENNESSEE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:EAST TENNESSEE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CORUM
Authorized Official - Suffix:II
Authorized Official - Credentials:PT OCS
Authorized Official - Phone:865-745-1799
Mailing Address - Street 1:4357 MAYNARDVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:MAYNARDVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4357 MAYNARDVILLE HWY
Practice Address - Street 2:
Practice Address - City:MAYNARDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37807
Practice Address - Country:US
Practice Address - Phone:865-745-1799
Practice Address - Fax:865-745-1806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-24
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5712261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy