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General NPI Number Information
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NPI Number | 1720766629
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Entity Type | Individual
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Provider Name | MUHAREM KOMIC MAT, PES
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Gender | Male
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Dates
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Enumeration Date | 07/10/2023
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Last Update Date | 07/10/2023
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Provider Practice Location Address
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Address Line | 210 LINDSEY WILSON ST
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City | COLUMBIA
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State | KY
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Zip | 42728-1223
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Country | US
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Telephone | 800-264-0138
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Fax |
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Provider Business Mailing Address
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Address Line | 419 W RIPA AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63125-2740
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Country | US
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Telephone | 314-680-9031
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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 |
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License Number State |
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