Healthcare Provider Details

I. General information

NPI: 1659315778
Provider Name (Legal Business Name): MATTHEW C COOK ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NORTH ST SUITE 2
SACO ME
04072-1867
US

IV. Provider business mailing address

400 NORTH ST SUITE 2
SACO ME
04072-1867
US

V. Phone/Fax

Practice location:
  • Phone: 207-282-7121
  • Fax: 207-282-0073
Mailing address:
  • Phone: 207-282-7121
  • Fax: 207-282-0073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT116
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: