Healthcare Provider Details

I. General information

NPI: 1861061996
Provider Name (Legal Business Name): DALE JUSTIN ARNOLD MHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1332 SOUTHERN DR
STATESBORO GA
30460-1360
US

IV. Provider business mailing address

130 LANIER DR APT 914
STATESBORO GA
30458-8024
US

V. Phone/Fax

Practice location:
  • Phone: 912-478-2674
  • Fax:
Mailing address:
  • Phone: 678-481-9264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: