Basic Information
| Provider Information | |||||||||
| NPI: | 1700149580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATIACO | ||||||||
| FirstName: | CAROLE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RD, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15895 SW 72ND AVE | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036245630 | ||||||||
| FaxNumber: | 5036249149 | ||||||||
| Practice Location | |||||||||
| Address1: | 15895 SW 72ND AVE | ||||||||
| Address2: | SUITE 250 BLDG B | ||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036245630 | ||||||||
| FaxNumber: | 5036249149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2012 | ||||||||
| LastUpdateDate: | 03/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 000965 | OR | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 5000662380 | 05 | OR | MEDICAID |