Healthcare Provider Details

I. General information

NPI: 1508226002
Provider Name (Legal Business Name): CHRISTOPHER WATSON LAT, ATC, CES, PES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2016
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 TECH FARM RD APT C-6
RUSTON LA
71270-5462
US

IV. Provider business mailing address

1408 TECH FARM RD APT C-6
RUSTON LA
71270-5462
US

V. Phone/Fax

Practice location:
  • Phone: 843-254-9202
  • Fax:
Mailing address:
  • Phone: 843-254-9202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATH.200475
License Number StateLA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: