Provider Demographics
NPI:1235293556
Name:HAYNES, MARK GLENN (ATC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:GLENN
Last Name:HAYNES
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 LEATHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3702
Mailing Address - Country:US
Mailing Address - Phone:870-424-3554
Mailing Address - Fax:
Practice Address - Street 1:302 LEATHERWOOD DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3702
Practice Address - Country:US
Practice Address - Phone:870-424-3554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer