Healthcare Provider Details

I. General information

NPI: 1295463610
Provider Name (Legal Business Name): TARYNCE HUDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 08/12/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4216 W 28TH ST.
PINE BLUFF AR
71603
US

IV. Provider business mailing address

7303 N HIGHWAY 79
SHERRILL AR
72152-8824
US

V. Phone/Fax

Practice location:
  • Phone: 501-653-3676
  • Fax:
Mailing address:
  • Phone: 870-592-0049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number1210681743
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number1210681743
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1210644080
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number1210681743
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: