Healthcare Provider Details

I. General information

NPI: 1215765672
Provider Name (Legal Business Name): DARIUS TREVON RICH MAT, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CENTRAL METHODIST SQ STE 1
FAYETTE MO
65248-1198
US

IV. Provider business mailing address

3601 W BROADWAY APT 32101
COLUMBIA MO
65203-7930
US

V. Phone/Fax

Practice location:
  • Phone: 660-248-6251
  • Fax:
Mailing address:
  • Phone: 660-631-7677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2023049011
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: