Healthcare Provider Details

I. General information

NPI: 1154703742
Provider Name (Legal Business Name): JOSEPH HARLEY PETTITT ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8880 NE 82ND TER
KANSAS CITY MO
64158-1313
US

IV. Provider business mailing address

8200 DEXTER CREEK LN UNIT 203
CORDOVA TN
38016-2066
US

V. Phone/Fax

Practice location:
  • Phone: 816-437-8122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: