Healthcare Provider Details

I. General information

NPI: 1497279640
Provider Name (Legal Business Name): MATTHEW MORRIS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 07/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 ANNE ST NW
BEMIDJI MN
56601-5103
US

IV. Provider business mailing address

3017 MELSHIR LN SW
BEMIDJI MN
56601-5785
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-6774
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2137
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: