Healthcare Provider Details

I. General information

NPI: 1881146074
Provider Name (Legal Business Name): ARTHUR HAIRSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 10/02/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5633 CLIFTON LANE
JACKSONVILLE FL
32211
US

IV. Provider business mailing address

87 PALISADE DR
ST AUGUSTINE FL
32092-1139
US

V. Phone/Fax

Practice location:
  • Phone: 904-503-0131
  • Fax:
Mailing address:
  • Phone: 704-965-4276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-40901
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: