Provider Demographics
NPI:1114340387
Name:HARGROVE, JUSTIN WISE (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:WISE
Last Name:HARGROVE
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1184
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75456-1184
Mailing Address - Country:US
Mailing Address - Phone:903-305-6456
Mailing Address - Fax:903-577-5550
Practice Address - Street 1:2110 N EDWARDS AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-2011
Practice Address - Country:US
Practice Address - Phone:903-434-8584
Practice Address - Fax:903-577-5550
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-24
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT19382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer