1154546513 NPI number — MARY A MATTOX

Table of content: MARY A MATTOX (NPI 1154546513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154546513 NPI number — MARY A MATTOX

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTOX
Provider First Name:
MARY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154546513
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6221
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOHAVE VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86446-6221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-768-4216
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8450 OLIVE AVE
Provider Second Line Business Practice Location Address:
MOHAVE VALLEY ELEM. SD16
Provider Business Practice Location Address City Name:
MOHAVE VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86440-9214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-768-2507
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YS0200X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 816431 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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