1861834483 NPI number — MATA-5 INC.

Table of content: (NPI 1861834483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861834483 NPI number — MATA-5 INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATA-5 INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1861834483
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 871249
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48187-6249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-335-6312
Provider Business Mailing Address Fax Number:
313-202-8233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6624 N CANTON CENTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48187-1651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-335-6312
Provider Business Practice Location Address Fax Number:
313-202-8233
Provider Enumeration Date:
07/24/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MATA
Authorized Official First Name:
WASHDEV
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
734-335-6312

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  5301010140 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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