=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033582903
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW HARRISON LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2015
-----------------------------------------------------
Last Update Date | 11/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11595 N MERIDIAN ST STE 140
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-4544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-708-4832
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 144 DIPLOMAT CT APT 9
-----------------------------------------------------
City | BEECH GROVE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46107-2343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-343-5128
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number | 2000018286
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------