1609001684 NPI number — MATT 25 INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609001684 NPI number — MATT 25 INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATT 25 INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIFE SKILLS LEARNING CENTER
Provider Other Organization Name Type Code:
3
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:
1609001684
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 THORNTON ST STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLOVIS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88101-5508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-763-4400
Provider Business Mailing Address Fax Number:
575-935-0400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 THORNTON ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88101-5508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-763-4400
Provider Business Practice Location Address Fax Number:
575-935-0400
Provider Enumeration Date:
05/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
RESHETAR
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
575-763-4400

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  0153271 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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