Healthcare Provider Details

I. General information

NPI: 1164199683
Provider Name (Legal Business Name): CANDICE PAIGE HOPKINS LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 09/25/2021
Certification Date: 09/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 DONAGHEY AVE
CONWAY AR
72035-5001
US

IV. Provider business mailing address

10 EARL DR
CONWAY AR
72032-9267
US

V. Phone/Fax

Practice location:
  • Phone: 205-771-0637
  • Fax:
Mailing address:
  • Phone: 205-771-0637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number959
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number959
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: