Healthcare Provider Details

I. General information

NPI: 1518555333
Provider Name (Legal Business Name): CLAYTON SIBLEY ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 01/07/2021
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

287 MS-6
BATESVILLE MS
38606
US

IV. Provider business mailing address

61 SULLIVANT RD
BATESVILLE MS
38606-9548
US

V. Phone/Fax

Practice location:
  • Phone: 662-578-7799
  • Fax:
Mailing address:
  • Phone: 166-293-4425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-0869
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: