MEDICARE: NATHAN MATLACK MT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT.0018968	CO

General Provider Information

NPI Number	:	1144773243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN MATLACK MT

Provider Business Mailing Address
First Line	:	3429 E LOCUST ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-8548
Country	:	US
Telephone Number	:	970-231-1431
Fax Number	:

Provider Business Practice Location Address
First Line	:	3429 E LOCUST ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-8548
Country	:	US
Telephone Number	:	970-231-1431
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2016
Last Update Date	:	07/26/2016

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