Healthcare Provider Details

I. General information

NPI: 1801315759
Provider Name (Legal Business Name): LARRY GENE HALYE JR. LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 W 23RD ST
HAZLE TOWNSHIP PA
18202-1647
US

IV. Provider business mailing address

200 MOORES HILL RD
BERWICK PA
18603-6219
US

V. Phone/Fax

Practice location:
  • Phone: 570-459-3221
  • Fax:
Mailing address:
  • Phone: 570-578-5980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRTO000437
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: