Healthcare Provider Details

I. General information

NPI: 1598289936
Provider Name (Legal Business Name): MATTHEW WOZNIAK MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 07/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 SW 30TH ST
DAVIE FL
33314-1020
US

IV. Provider business mailing address

2110 NORTH AVE
WAUKEGAN IL
60087-5108
US

V. Phone/Fax

Practice location:
  • Phone: 954-452-7071
  • Fax:
Mailing address:
  • Phone: 847-239-4536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL4991
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: