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General NPI Number Information
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NPI Number | 1588075121
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Entity Type | Individual
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Provider Name | MATTHEW CHARLEW SMITLEY DAT, LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 05/16/2014
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Last Update Date | 09/02/2020
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Provider Practice Location Address
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Address Line | 875 PERIMETER DR # MS 2401
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City | MOSCOW
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State | ID
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Zip | 83844-7462
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Country | US
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Telephone | 208-885-0349
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Fax | 208-885-5929
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Provider Business Mailing Address
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Address Line | 320 OPAL BROOK DR
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City | ELIZABETHTON
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State | TN
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Zip | 37643-7462
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Country | US
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Telephone |
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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 | LAT-2518
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT-642
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License Number State | ID
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