Healthcare Provider Details

I. General information

NPI: 1285632596
Provider Name (Legal Business Name): MATTHEW THOMAS HENRY MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3051 WATSON BLVD
WARNER ROBINS GA
31093-8536
US

IV. Provider business mailing address

113 E. OAK ST.
MC RAE GA
31055-1550
US

V. Phone/Fax

Practice location:
  • Phone: 478-953-4563
  • Fax: 478-953-4564
Mailing address:
  • Phone: 229-868-2174
  • Fax: 229-868-2175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT008256
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: