1750446837 NPI number — CHRISTOPHER COREY DIMATTIA DPT

Table of content: CHRISTOPHER COREY DIMATTIA DPT (NPI 1750446837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750446837 NPI number — CHRISTOPHER COREY DIMATTIA DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIMATTIA
Provider First Name:
CHRISTOPHER
Provider Middle Name:
COREY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

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:
1750446837
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8521 E CYPRESS POINT CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70809-2283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-235-6161
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28977 WALKER SOUTH ROAD
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
WALKER
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-271-8056
Provider Business Practice Location Address Fax Number:
225-271-8057
Provider Enumeration Date:
12/27/2006

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: 225100000X , with the licence number:  07076 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07076 . This is a "STATE LICENSE #" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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