Healthcare Provider Details

I. General information

NPI: 1972426476
Provider Name (Legal Business Name): SPENCER DECKER MAT, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 ROGERS ST
COLUMBIA MO
65216-0001
US

IV. Provider business mailing address

3603 W BROADWAY APT 8208
COLUMBIA MO
65203-0148
US

V. Phone/Fax

Practice location:
  • Phone: 573-875-7674
  • Fax:
Mailing address:
  • Phone: 870-759-8048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2025028367
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: