1083876601 NPI number — MISS MELISSA MARIE MATAMOROS OTR

Table of content: MISS MELISSA MARIE MATAMOROS OTR (NPI 1083876601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083876601 NPI number — MISS MELISSA MARIE MATAMOROS OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATAMOROS
Provider First Name:
MELISSA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
OTR
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:
1083876601
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12710 RESEARCH BLVD
Provider Second Line Business Mailing Address:
SUITE 395
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78759-4379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-331-4115
Provider Business Mailing Address Fax Number:
512-331-8176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12710 RESEARCH BLVD
Provider Second Line Business Practice Location Address:
SUITE 395
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78759-4379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-331-4115
Provider Business Practice Location Address Fax Number:
512-331-8176
Provider Enumeration Date:
06/25/2008

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: 225XP0200X , with the licence number:  110860 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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