Provider Demographics
NPI:1376929877
Name:GRECO, TARA (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GRECO
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 480
Mailing Address - Street 2:
Mailing Address - City:STATE UNIVERSITY
Mailing Address - State:AR
Mailing Address - Zip Code:72467-0480
Mailing Address - Country:US
Mailing Address - Phone:870-972-3342
Mailing Address - Fax:
Practice Address - Street 1:217 OLYMPIC DRIVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-972-3342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT6862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARAT686OtherLICENSED ATHLETIC TRAINER