MEDICARE: MR. RANDELL GENE MATTHEWS ATC., LAT

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	2255A2300X	Athletic Trainer	AT0374	TX

General Provider Information

NPI Number	:	1487622403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDELL GENE MATTHEWS ATC., LAT

Provider Business Mailing Address
First Line	:	3107 HEMLOCK DR
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-6118
Country	:	US
Telephone Number	:	325-944-3688
Fax Number	:	325-224-5911

Provider Business Practice Location Address
First Line	:	3501 KNICKERBOCKER RD
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-7610
Country	:	US
Telephone Number	:	325-949-4357
Fax Number	:	325-224-5911

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

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	07/08/2007

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