Healthcare Provider Details

I. General information

NPI: 1053138925
Provider Name (Legal Business Name): MALENA EAVES ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3533 MATLOCK RD
ARLINGTON TX
76015-3604
US

IV. Provider business mailing address

8200 GLENN DAY DR APT 2210
ARLINGTON TX
76002-4348
US

V. Phone/Fax

Practice location:
  • Phone: 817-419-0303
  • Fax:
Mailing address:
  • Phone: 817-965-4618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT8520
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: