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General NPI Number Information
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NPI Number | 1700878196
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Entity Type | Individual
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Provider Name | BRIAN EDWARD CONWAY ATC; LAT
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Gender | Male
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Dates
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Enumeration Date | 08/22/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 800 5TH AVE SUITE 150
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City | FORT WORTH
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State | TX
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Zip | 76104-7300
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Country | US
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Telephone | 817-810-7504
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Fax | 817-810-7501
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Provider Business Mailing Address
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Address Line | 2105 EDGEWOOD CT
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City | ARLINGTON
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State | TX
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Zip | 76013-5408
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Country | US
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Telephone | 817-810-7504
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Fax | 817-810-7501
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 0803
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License Number State | TX
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