Healthcare Provider Details

I. General information

NPI: 1679536734
Provider Name (Legal Business Name): FREDRICK EARL WORTHY ATC/L
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BORDER AVE E
WIGGINS MS
39577-2822
US

IV. Provider business mailing address

328 STILLWAY DR
WIGGINS MS
39577-2902
US

V. Phone/Fax

Practice location:
  • Phone: 601-928-5492
  • Fax:
Mailing address:
  • Phone: 601-503-0824
  • Fax: 601-928-6874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0152
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: