Healthcare Provider Details

I. General information

NPI: 1386528487
Provider Name (Legal Business Name): JONATHAN N TRAIL RT (R), RVT (VT)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2025
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3318
US

IV. Provider business mailing address

3008 CANTERBURY
PARAGOULD AR
72450-7790
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-4151
  • Fax:
Mailing address:
  • Phone: 870-476-2923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number483202
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number168994
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: