Healthcare Provider Details

I. General information

NPI: 1568984581
Provider Name (Legal Business Name): CORDARIUS WAYNE ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 07/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 W UNION ST STE A
MINDEN LA
71055-3216
US

IV. Provider business mailing address

100 S LAKE CIR
MONROE LA
71203-6947
US

V. Phone/Fax

Practice location:
  • Phone: 318-299-6334
  • Fax: 318-299-6332
Mailing address:
  • Phone: 318-537-0280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number300123
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: