Basic Information
| Provider Information | |||||||||
| NPI: | 1285858498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATA | ||||||||
| FirstName: | CARLOS | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7364 WHISTLEWOOD SW | ||||||||
| Address2: | |||||||||
| City: | BYRON CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493158139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165830950 | ||||||||
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| Practice Location | |||||||||
| Address1: | 709 W SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | WAYLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493481226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2697924440 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501001635 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.