Healthcare Provider Details

I. General information

NPI: 1497717896
Provider Name (Legal Business Name): DOIN WAYNE DAHLKE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 FAYETTEVILLE RD SUITE 202
VAN BUREN AR
72956-3426
US

IV. Provider business mailing address

1031 FAYETTEVILLE RD SUITE 202
VAN BUREN AR
72956-3426
US

V. Phone/Fax

Practice location:
  • Phone: 479-474-6099
  • Fax: 479-474-6099
Mailing address:
  • Phone: 479-474-6099
  • Fax: 479-474-6099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 119
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: