Healthcare Provider Details

I. General information

NPI: 1023000981
Provider Name (Legal Business Name): ARKANSAS STATE UNIVERSITY ATHLETIC TRAINING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 U STREET
JONESBORO AR
72401
US

IV. Provider business mailing address

2 U STREET
JONESBORO AR
72401
US

V. Phone/Fax

Practice location:
  • Phone: 870-972-3342
  • Fax: 870-972-2052
Mailing address:
  • Phone: 870-972-3342
  • Fax: 870-972-2052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RON CARROLL
Title or Position: HEAD ATHLETIC TRAINER
Credential: ATC, LAT
Phone: 870-972-3342