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General NPI Number Information
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NPI Number | 1164031050
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Entity Type | Individual
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Provider Name | MATTHEW JOHNSON ATC
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Gender | Male
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Dates
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Enumeration Date | 07/27/2020
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Last Update Date | 07/27/2020
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Provider Practice Location Address
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Address Line | 1300 WHEAT ST
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City | COLUMBIA
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State | SC
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Zip | 29208-0001
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Country | US
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Telephone | 919-356-7356
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Fax |
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Provider Business Mailing Address
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Address Line | 3109 JEFFERSON DAVIS HWY
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City | SANFORD
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State | NC
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Zip | 27332-7117
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Country | US
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Telephone | 919-356-7356
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000038912
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License Number State | NC
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