Healthcare Provider Details

I. General information

NPI: 1952875171
Provider Name (Legal Business Name): ADAM LUCAS HOTALING ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 FORTENBERRY RD
DECATUR TX
76234-5817
US

IV. Provider business mailing address

951 FORTENBERRY RD
DECATUR TX
76234-5817
US

V. Phone/Fax

Practice location:
  • Phone: 607-423-3870
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT4214
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: