Healthcare Provider Details

I. General information

NPI: 1700878196
Provider Name (Legal Business Name): BRIAN EDWARD CONWAY ATC; LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 5TH AVE SUITE 150
FORT WORTH TX
76104-7300
US

IV. Provider business mailing address

2105 EDGEWOOD CT
ARLINGTON TX
76013-5408
US

V. Phone/Fax

Practice location:
  • Phone: 817-810-7504
  • Fax: 817-810-7501
Mailing address:
  • Phone: 817-810-7504
  • Fax: 817-810-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0803
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: