1730845249 NPI number — MARIAM PRINCESS IKHARO-MATLOCK

Table of content: MARIAM PRINCESS IKHARO-MATLOCK (NPI 1730845249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730845249 NPI number — MARIAM PRINCESS IKHARO-MATLOCK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IKHARO-MATLOCK
Provider First Name:
MARIAM
Provider Middle Name:
PRINCESS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1730845249
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1879 MOUNT GOETHE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANTIOCH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94531-9077
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-904-8656
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1879 MOUNT GOETHE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANTIOCH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94531-9077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-904-8656
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/10/2021

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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