Provider Demographics
NPI:1326363029
Name:MCCLAIN, GREGORY MATTHEW (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:MATTHEW
Last Name:MCCLAIN
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 649
Mailing Address - Street 2:
Mailing Address - City:WESSON
Mailing Address - State:MS
Mailing Address - Zip Code:39191-0649
Mailing Address - Country:US
Mailing Address - Phone:601-643-8481
Mailing Address - Fax:601-643-8525
Practice Address - Street 1:1028 JC REDD DRIVE
Practice Address - Street 2:
Practice Address - City:WESSON
Practice Address - State:MS
Practice Address - Zip Code:39191-0649
Practice Address - Country:US
Practice Address - Phone:601-643-8481
Practice Address - Fax:601-643-8525
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT02992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer