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NPI Code Detail

MEDICARE: MOLLIE KLOSTER MAT, ATC, LAT

MEDICARE: MOLLIE KLOSTER MAT, ATC, LAT
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
12255A2300XAthletic Trainer36004173AIN

General Provider Information

NPI Number : 1548195639
Entity Type Code : Individual
Provider Name (Legal Business Name) : MOLLIE KLOSTER MAT, ATC, LAT
Provider Business Mailing Address
First Line : 3946 ICE WAY
Second Line :
City : FORT WAYNE
State : IN
Zip : 46805-1018
Country : US
Telephone Number : 260-437-7220
Fax Number :
Provider Business Practice Location Address
First Line : 3946 ICE WAY
Second Line :
City : FORT WAYNE
State : IN
Zip : 46805-1018
Country : US
Telephone Number : 260-437-7220
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/17/2026
Last Update Date : 06/17/2026

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Directions to “ MOLLIE KLOSTER MAT, ATC, LAT” Practice Location

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