Provider Demographics
NPI:1376071936
Name:PRESTON, MATTHEW S
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:PRESTON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MATTHEW
Other - Middle Name:S
Other - Last Name:PRESTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATC, LAT
Mailing Address - Street 1:211 RED BIRD LANE
Mailing Address - Street 2:CAMPUS BOX 10611 / ATHLETIC TRAINING
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 REDBIRD LN
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77705-9801
Practice Address - Country:US
Practice Address - Phone:409-880-2359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-26
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT68002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty