Basic Information
| Provider Information | |||||||||
| NPI: | 1114407376 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLK | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | GRANBURY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760481496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174083800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | GRANBURY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760481496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174083800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2018 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2084076 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.