MEDICARE: MATTHEW LOUIS ENNIS A.T.,C.

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	AL 796	FL

General Provider Information

NPI Number	:	1891960837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW LOUIS ENNIS A.T.,C.

Provider Business Mailing Address
First Line	:	4104 1ST AVE W
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34209-2057
Country	:	US
Telephone Number	:	941-238-8592
Fax Number	:

Provider Business Practice Location Address
First Line	:	5840 26TH ST W
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34207-3522
Country	:	US
Telephone Number	:	941-752-5574
Fax Number	:

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

Provider Enumeration Date	:	04/29/2008
Last Update Date	:	04/29/2008

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