Healthcare Provider Details

I. General information

NPI: 1669074126
Provider Name (Legal Business Name): DILLON BARTHOLOMEW DAVIS LAT,ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14043 HIGHWAY 32
SUCCESS MO
65570-9748
US

IV. Provider business mailing address

14043 HIGHWAY 32
SUCCESS MO
65570-9748
US

V. Phone/Fax

Practice location:
  • Phone: 417-217-2380
  • Fax:
Mailing address:
  • Phone: 417-217-2380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2020026907
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: