Healthcare Provider Details

I. General information

NPI: 1982676839
Provider Name (Legal Business Name): KEMBRA LEA MATHIS ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2006
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 SE J ST
BENTONVILLE AR
72712-4295
US

IV. Provider business mailing address

1601 CRESENT ST
BENTONVILLE AR
72712-9411
US

V. Phone/Fax

Practice location:
  • Phone: 479-254-5100
  • Fax:
Mailing address:
  • Phone: 479-877-9345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 419
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: