=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427407584
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW CHARLES WOOD MS, AT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2016
-----------------------------------------------------
Last Update Date | 06/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 946 STONE RIDGE LN
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45036-8530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-378-3910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 270 S LOCUST ST
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45056-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-378-3910
-----------------------------------------------------
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 | AT. 004088
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------