Provider Demographics
NPI:1922185644
Name:TRI STATE SPORTS MEDICINE AND REHABILITATION INC
Entity type:Organization
Organization Name:TRI STATE SPORTS MEDICINE AND REHABILITATION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:CORUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-626-7848
Mailing Address - Street 1:PO BOX 1310
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-1310
Mailing Address - Country:US
Mailing Address - Phone:865-805-1218
Mailing Address - Fax:423-626-7849
Practice Address - Street 1:2255 HIGHWAY 25E STE 4
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37879
Practice Address - Country:US
Practice Address - Phone:423-626-7848
Practice Address - Fax:423-626-7849
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI STATE SPORTS MEDICINE AND REHABILITAION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3108225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9894Medicare ID - Type UnspecifiedMEDICARE FOR KY