1306855168 NPI number — VINCENT T MATTIELLO DC

Table of content: ROBERT BOUTIN (NPI 1548864572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306855168 NPI number — VINCENT T MATTIELLO DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTIELLO
Provider First Name:
VINCENT
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1306855168
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29 BIG BUCK TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORMOND BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32174-4279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-405-0652
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2845 ENTERPRISE RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
DEBARY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32713-5224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-668-9200
Provider Business Practice Location Address Fax Number:
386-668-9200
Provider Enumeration Date:
08/07/2006

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: 111N00000X , with the licence number:  CH9167 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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