=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194853002
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JARED F MATKOWSKI LATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2928 MAIN ST EASTERN REHABILITATION NETWORK
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-1007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-657-4723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 MCKEE ST APT K
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-4859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-432-3581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 000088
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------