Healthcare Provider Details

I. General information

NPI: 1326025552
Provider Name (Legal Business Name): MATHEW JON LYDEN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 CHURCH ST BOX 18
NASHVILLE TN
37236-0001
US

IV. Provider business mailing address

7301 SUTTON PL
FAIRVIEW TN
37062-9353
US

V. Phone/Fax

Practice location:
  • Phone: 615-284-4808
  • Fax: 615-284-4811
Mailing address:
  • Phone: 615-799-7822
  • Fax: 615-284-4811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0000000472
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: