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NPI Code Detail

MEDICARE: ELLEN KLUTH MAT, LAT, ATC

MEDICARE: ELLEN KLUTH MAT, LAT, ATC
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
12255A2300XAthletic Trainer0622SD

General Provider Information

NPI Number : 1316524374
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELLEN KLUTH MAT, LAT, ATC
Provider Business Mailing Address
First Line : 8900 W WISEMAN CIR
Second Line :
City : SIOUX FALLS
State : SD
Zip : 57106-4846
Country : US
Telephone Number : 605-630-8863
Fax Number :
Provider Business Practice Location Address
First Line : 6800 S LOUISE AVE
Second Line :
City : SIOUX FALLS
State : SD
Zip : 57108-6026
Country : US
Telephone Number : 605-630-8863
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/25/2021
Last Update Date : 03/25/2021

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Directions to “ ELLEN KLUTH MAT, LAT, ATC” Practice Location

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