Healthcare Provider Details

I. General information

NPI: 1043958648
Provider Name (Legal Business Name): CAROLINE DENT MAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2022
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 MCFARLAND BLVD
NORTHPORT AL
35476-3348
US

IV. Provider business mailing address

6323 WOODLAND FORREST DR
TUSCALOOSA AL
35405-5672
US

V. Phone/Fax

Practice location:
  • Phone: 205-344-9161
  • Fax:
Mailing address:
  • Phone: 205-765-2028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2782
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: