Provider Demographics
NPI:1215477724
Name:BRIDGES, MATT (ATC)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:BRIDGES
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3872 JEWELL ST
Mailing Address - Street 2:H312
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-6421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3872 JEWELL ST
Practice Address - Street 2:H312
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-6421
Practice Address - Country:US
Practice Address - Phone:858-353-1769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000026732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer