Healthcare Provider Details

I. General information

NPI: 1336663111
Provider Name (Legal Business Name): KELLY THOMAS ARENDS M.ED, LAT, ATC,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 WESTMINSTER AVE
FULTON MO
65251-1299
US

IV. Provider business mailing address

411 CENTRAL METHODIST SQ
FAYETTE MO
65248-1104
US

V. Phone/Fax

Practice location:
  • Phone: 573-592-5332
  • Fax:
Mailing address:
  • Phone: 660-248-6978
  • Fax: 660-248-6381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2017010116
License Number StateMO

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: