Healthcare Provider Details

I. General information

NPI: 1538607635
Provider Name (Legal Business Name): MATTHEW BOWDEN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 S KINGSHIGHWAY ST
SAINT CHARLES MO
63301-1695
US

IV. Provider business mailing address

8814 OAK CREEK DR
SAINT LOUIS MO
63126-2130
US

V. Phone/Fax

Practice location:
  • Phone: 636-949-4949
  • Fax:
Mailing address:
  • Phone: 402-203-3457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number2016032815
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2016032815
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: