Provider Demographics
NPI:1730503913
Name:DIESER, COREY (DPT)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:DIESER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:400 OVESEN DR
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:IA
Practice Address - Zip Code:52778-9612
Practice Address - Country:US
Practice Address - Phone:563-732-4317
Practice Address - Fax:536-732-4318
Is Sole Proprietor?:No
Enumeration Date:2014-02-09
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA005327225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist