Healthcare Provider Details

I. General information

NPI: 1912223165
Provider Name (Legal Business Name): KEVIN MATHIS ROBERTS A.T.,C. , M ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10590 TOWN CENTER DR STE 100
RANCHO CUCAMONGA CA
91730-0361
US

IV. Provider business mailing address

10590 TOWN CENTER DR STE 100
RANCHO CUCAMONGA CA
91730-0361
US

V. Phone/Fax

Practice location:
  • Phone: 909-948-1124
  • Fax:
Mailing address:
  • Phone: 909-948-1124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: