Healthcare Provider Details

I. General information

NPI: 1558767483
Provider Name (Legal Business Name): SAMANTHA BOURCY MATRG, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 17TH AVE E SUITE 101
ALEXANDRIA MN
56308-5273
US

IV. Provider business mailing address

111 17TH AVE E SUITE 101
ALEXANDRIA MN
56308-5273
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-1144
  • Fax: 320-762-1935
Mailing address:
  • Phone: 320-762-1144
  • Fax: 320-762-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number503-13
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2634
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: