Healthcare Provider Details

I. General information

NPI: 1972872794
Provider Name (Legal Business Name): NATHAN LEE HARALSON ATC/L, CDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 I-55 SERVICE ROAD SUITE C
MARION AR
72364
US

IV. Provider business mailing address

1115 CLEMENT RD
WEST MEMPHIS AR
72301-2451
US

V. Phone/Fax

Practice location:
  • Phone: 870-514-6224
  • Fax:
Mailing address:
  • Phone: 870-514-6224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT430
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: