Healthcare Provider Details

I. General information

NPI: 1881826048
Provider Name (Legal Business Name): MEREDITH MADDEN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 BABCOCK ST
BOSTON MA
02215-1003
US

IV. Provider business mailing address

23 MYRTLE ST
WATERTOWN MA
02472-2371
US

V. Phone/Fax

Practice location:
  • Phone: 617-353-2746
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1996
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: