Basic Information
Provider Information | |||||||||
NPI: | 1649206467 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MATRIX REHABILITATION, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SELECT PHYSICAL THERAPY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4714 GETTYSBURG RD | ||||||||
Address2: |   | ||||||||
City: | MECHANICSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 170554325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7179754510 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 707 LINCOLN CTR | ||||||||
Address2: |   | ||||||||
City: | STOCKTON | ||||||||
State: | CA | ||||||||
PostalCode: | 952072644 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2094783900 | ||||||||
FaxNumber: | 2094783979 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2006 | ||||||||
LastUpdateDate: | 03/15/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TARVIN | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | E. | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7179721132 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.