1194879312 NPI number — DR. SHIRLEY ANN MATA D.C

Table of content: DR. SHIRLEY ANN MATA D.C (NPI 1194879312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194879312 NPI number — DR. SHIRLEY ANN MATA D.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATA
Provider First Name:
SHIRLEY
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C
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:
1194879312
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 962037
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79996-2037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-252-9832
Provider Business Mailing Address Fax Number:
915-594-8972

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10600 MONTWOOD DR
Provider Second Line Business Practice Location Address:
SUITE 113
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79935-2700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-252-9832
Provider Business Practice Location Address Fax Number:
915-595-6953
Provider Enumeration Date:
01/23/2007

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: 111NX0100X , with the licence number:  DC6402 , 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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