Provider Demographics
NPI:1912566092
Name:ADAMS, MATTHEW WAYNE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WAYNE
Last Name:ADAMS
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 1:2301 E ARDEN DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6890
Mailing Address - Country:US
Mailing Address - Phone:812-361-9947
Mailing Address - Fax:
Practice Address - Street 1:2301 E ARDEN DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6890
Practice Address - Country:US
Practice Address - Phone:812-361-9947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36003265A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer