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General NPI Number Information
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NPI Number | 1861899270
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Entity Type | Individual
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Provider Name | MATTHEW BERG MS, LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 12/01/2014
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Last Update Date | 12/13/2016
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Provider Practice Location Address
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Address Line | 1988 S 1100 E UNIT 506
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City | SALT LAKE CITY
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State | UT
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Zip | 84106-4723
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Country | US
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Telephone | 715-587-5531
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Fax |
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Provider Business Mailing Address
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Address Line | 1988 S 1100 E UNIT 506
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City | SALT LAKE CITY
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State | UT
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Zip | 84106-4723
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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 | 9809678-4810
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License Number State | UT
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