Provider Demographics
NPI:1063996304
Name:VAIL, MATTHEW (AT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:VAIL
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 14TH AVE SE APT 310
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-5983
Mailing Address - Country:US
Mailing Address - Phone:913-271-1739
Mailing Address - Fax:
Practice Address - Street 1:500 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58707-0001
Practice Address - Country:US
Practice Address - Phone:913-271-1739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-22
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
ND2255A2300X
ND855-192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer