Provider Demographics
NPI:1982624250
Name:CORUM, DALE R II (PT)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:R
Last Name:CORUM
Suffix:II
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:MAYNARDVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37807-0096
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:37807-3623
Practice Address - Country:US
Practice Address - Phone:865-745-1799
Practice Address - Fax:865-745-1806
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004863225100000X
TNPT0000005712225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0989402Medicare ID - Type Unspecified