Provider Demographics
NPI:1629497896
Name:GRIFFIS, EDWARD (ATC/LAT)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:GRIFFIS
Suffix:
Gender:M
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 1:2712 CANTERBURY CIR
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5259
Mailing Address - Country:US
Mailing Address - Phone:479-629-3264
Mailing Address - Fax:
Practice Address - Street 1:4100 GARY ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5456
Practice Address - Country:US
Practice Address - Phone:479-629-3264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR153OtherLIC. ATHLETIC TRAINER