Healthcare Provider Details

I. General information

NPI: 1760600704
Provider Name (Legal Business Name): CORRIE HAZELWOOD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 DAHLKE DR
CULLMAN AL
35058-3625
US

IV. Provider business mailing address

172 MIRANDA RD
WARRIOR AL
35180
US

V. Phone/Fax

Practice location:
  • Phone: 256-739-1370
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number931
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: