Healthcare Provider Details

I. General information

NPI: 1538133459
Provider Name (Legal Business Name): SHAWN MICHAEL TACKETT MS, ATC/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 HIGHLAND RD
BATESVILLE AR
72501-3629
US

IV. Provider business mailing address

10 BIG PINE RD
BATESVILLE AR
72501-7375
US

V. Phone/Fax

Practice location:
  • Phone: 870-307-7331
  • Fax: 870-307-7524
Mailing address:
  • Phone: 870-834-4731
  • Fax: 870-307-7524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 362
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: