Healthcare Provider Details

I. General information

NPI: 1538901822
Provider Name (Legal Business Name): MASON ANDREW COOKSEY MAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/10/2024
Certification Date: 05/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MIAMI VALLEY DR
CENTERVILLE OH
45459-4774
US

IV. Provider business mailing address

241 W 2ND ST
XENIA OH
45385-3527
US

V. Phone/Fax

Practice location:
  • Phone: 937-438-2400
  • Fax:
Mailing address:
  • Phone: 513-601-6650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT006964
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: