Healthcare Provider Details

I. General information

NPI: 1770630295
Provider Name (Legal Business Name): MATTHEW SCOTT REINERTSON ATC, OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 04/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 1ST STREET SOUTH STE 220
WILLMAR MN
56201-3556
US

IV. Provider business mailing address

111 17TH AVE E SUITE 101
ALEXANDRIA MN
56308-3734
US

V. Phone/Fax

Practice location:
  • Phone: 320-214-7355
  • Fax: 320-214-7356
Mailing address:
  • Phone: 320-762-1144
  • Fax: 320-762-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1077
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: