Provider Demographics
NPI:1720419609
Name:HUDSON, BRIAN (ATC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:HUDSON
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 1:419 PEARL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-5587
Mailing Address - Country:US
Mailing Address - Phone:606-776-3643
Mailing Address - Fax:
Practice Address - Street 1:419 PEARL CREEK DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-5587
Practice Address - Country:US
Practice Address - Phone:606-776-3643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110192272255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer