MEDICARE: MR. TODD MIKEL MATZ LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AT2679	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22	OTHER	TX	ATHLETIC TRAINER

General Provider Information

NPI Number	:	1396862140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TODD MIKEL MATZ LAT, ATC

Provider Business Mailing Address
First Line	:	4603 CYPRESSWOOD DR APT V13
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77379-8345
Country	:	US
Telephone Number	:	281-825-6724
Fax Number	:

Provider Business Practice Location Address
First Line	:	16713 ELLA BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090-4213
Country	:	US
Telephone Number	:	281-586-1364
Fax Number	:	281-586-1373

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	07/08/2007

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