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General NPI Number Information
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NPI Number | 1952842361
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Entity Type | Individual
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Provider Name | MADDOX LANDON REED ATC, LAT, GT
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Gender | Male
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Dates
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Enumeration Date | 03/17/2017
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Last Update Date | 03/17/2017
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Provider Practice Location Address
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Address Line | 107 TREMONT ST
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City | HOPEDALE
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State | IL
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Zip | 61747-7525
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Country | US
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Telephone | 313-586-2490
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Fax |
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Provider Business Mailing Address
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Address Line | 25739 BEECH CT
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City | REDFORD
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State | MI
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Zip | 48239-1703
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Country | US
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Telephone | 313-586-2490
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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 | 096004008
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License Number State | IL
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