Basic Information
| Provider Information | |||||||||
| NPI: | 1689908758 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATO | ||||||||
| FirstName: | CARMEN | ||||||||
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| Credential: | CSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 W END AVE | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153455400 | ||||||||
| FaxNumber: | 8884686511 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SARNO RD | ||||||||
| Address2: | SUITE 15 | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329354938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003484565 | ||||||||
| FaxNumber: | 8884686511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2009 | ||||||||
| LastUpdateDate: | 09/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | 02180 | FL | Y |
No ID Information.