Healthcare Provider Details

I. General information

NPI: 1114804788
Provider Name (Legal Business Name): CHAD HANES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 QUINN ST
HATTIESBURG MS
39401-4731
US

IV. Provider business mailing address

2101 QUINN ST
HATTIESBURG MS
39401-4731
US

V. Phone/Fax

Practice location:
  • Phone: 601-618-8021
  • Fax:
Mailing address:
  • Phone: 601-618-8021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: