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General NPI Number Information
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NPI Number | 1417098443
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Entity Type | Individual
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Provider Name | ALMA RAE MATTOCKS ATC
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Gender | Female
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Dates
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Enumeration Date | 02/11/2007
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Last Update Date | 01/10/2019
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Provider Practice Location Address
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Address Line | 2043 COLLEGE WAY
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City | FOREST GROVE
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State | OR
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Zip | 97116-1756
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Country | US
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Telephone | 503-352-2780
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Fax |
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Provider Business Mailing Address
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Address Line | NORTHERN KENTUCKY UNIVERSITY NUNN DRIVE / HC 116
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City | HIGHLAND HEIGHTS
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State | KY
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Zip | 41099
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Country | US
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Telephone | 503-880-0457
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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 | AT-AT-1005014
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License Number State | OR
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