Basic Information
| Provider Information | |||||||||
| NPI: | 1720741952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATIS | ||||||||
| FirstName: | MIRANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1105 W RUSSELL ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571041322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052712690 | ||||||||
| FaxNumber: | 6052713956 | ||||||||
| Practice Location | |||||||||
| Address1: | 735 3RD ST SW | ||||||||
| Address2: | |||||||||
| City: | PERHAM | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565731152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052712690 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2021 | ||||||||
| LastUpdateDate: | 10/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 373H00000X | MN | Y | Nursing Service Related Providers | Day Training/Habilitation Specialist |
No ID Information.