Basic Information
| Provider Information | |||||||||
| NPI: | 1659334845 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOSCHKE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | ATC, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11117 KEMPTON VISTA DR | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335694004 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 13020 N TELECOM PKWY | ||||||||
| Address2: | |||||||||
| City: | TEMPLE TERRACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336370925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139789700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.