Provider Demographics
NPI:1629440276
Name:REBUCK, MATTHEW RAY (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:RAY
Last Name:REBUCK
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2088 POWDERHORN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17057-5971
Mailing Address - Country:US
Mailing Address - Phone:717-903-0016
Mailing Address - Fax:
Practice Address - Street 1:1160 MANHEIM PIKE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-3127
Practice Address - Country:US
Practice Address - Phone:717-903-0016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0062572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer