Provider Demographics
NPI:1962535054
Name:HOLDER, MATTHEW WAYNE (ATC)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:WAYNE
Last Name:HOLDER
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 1:509 KEELEY AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTT CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63780-1631
Mailing Address - Country:US
Mailing Address - Phone:573-264-3632
Mailing Address - Fax:
Practice Address - Street 1:3047 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6393
Practice Address - Country:US
Practice Address - Phone:573-339-5989
Practice Address - Fax:573-339-7092
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1139072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer