Healthcare Provider Details

I. General information

NPI: 1780155374
Provider Name (Legal Business Name): MICHAEL HLAVATY ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2018
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4529 E FRYE RD
PHOENIX AZ
85048-7601
US

IV. Provider business mailing address

4529 E FRYE RD
PHOENIX AZ
85048-7601
US

V. Phone/Fax

Practice location:
  • Phone: 620-617-7371
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: