Provider Demographics
NPI:1053811828
Name:BOWLES, JUSTIN KYLE (ATC, LAT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:KYLE
Last Name:BOWLES
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 1:410 OUACHITA ST OBU BOX 3652
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71998-0001
Mailing Address - Country:US
Mailing Address - Phone:870-245-5280
Mailing Address - Fax:870-245-5242
Practice Address - Street 1:410 OUACHITA ST ATHLETIC TRAINING- SPEC
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71998-0001
Practice Address - Country:US
Practice Address - Phone:870-245-5280
Practice Address - Fax:870-245-5242
Is Sole Proprietor?:No
Enumeration Date:2018-02-18
Last Update Date:2018-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer