Healthcare Provider Details

I. General information

NPI: 1386093201
Provider Name (Legal Business Name): WILLIAM HUDSON BYRNES ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2016
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SOUTH CAPITOL STREET
CLINTON MS
39058
US

IV. Provider business mailing address

1208 RESERVE DR
CLINTON MS
39056-5655
US

V. Phone/Fax

Practice location:
  • Phone: 601-925-7641
  • Fax:
Mailing address:
  • Phone: 601-529-1582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0709
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: