Provider Demographics
NPI:1972166643
Name:MCCALLISTER, VINCENT MATTHEW (LAT, ATC)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:MATTHEW
Last Name:MCCALLISTER
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 1:1701 BLUE AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-2499
Mailing Address - Country:US
Mailing Address - Phone:740-453-0335
Mailing Address - Fax:740-455-4329
Practice Address - Street 1:1701 BLUE AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2457
Practice Address - Country:US
Practice Address - Phone:740-453-0335
Practice Address - Fax:740-455-4329
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH25852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer