Healthcare Provider Details

I. General information

NPI: 1649793019
Provider Name (Legal Business Name): WILLIAM BRADLEY ADERHOLT LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CAPITOL ST
CLINTON MS
39056-4026
US

IV. Provider business mailing address

6721 WASHINGTON AVE APT 7I
OCEAN SPRINGS MS
39564-2139
US

V. Phone/Fax

Practice location:
  • Phone: 601-925-3000
  • Fax:
Mailing address:
  • Phone: 662-436-3571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0844
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: