Healthcare Provider Details

I. General information

NPI: 1316474885
Provider Name (Legal Business Name): CHARLES ALAN WARDLAW ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 05/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W HOLLY RD
JUNCTION CITY AR
71749-9031
US

IV. Provider business mailing address

PO BOX 269
JUNCTION CITY AR
71749-0269
US

V. Phone/Fax

Practice location:
  • Phone: 870-924-4575
  • Fax:
Mailing address:
  • Phone: 870-403-4648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number694
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: