Healthcare Provider Details

I. General information

NPI: 1861956641
Provider Name (Legal Business Name): DAVID L HUDSON LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2019
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 S MOUNT AUBURN RD
CAPE GIRARDEAU MO
63703-4939
US

IV. Provider business mailing address

180 GLEN OAK DR
JACKSON MO
63755-8639
US

V. Phone/Fax

Practice location:
  • Phone: 573-519-4960
  • Fax:
Mailing address:
  • Phone: 573-517-2885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2020001583
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: