Provider Demographics
NPI:1033304357
Name:MATIN, MAHMOUD (DC)
Entity Type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:
Last Name:MATIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 S AZUSA AVE
Mailing Address - Street 2:SUITE B6
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-4088
Mailing Address - Country:US
Mailing Address - Phone:626-917-8706
Mailing Address - Fax:626-917-8759
Practice Address - Street 1:1414 S AZUSA AVE STE B6
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-4088
Practice Address - Country:US
Practice Address - Phone:626-917-8706
Practice Address - Fax:626-917-8759
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23316111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC23316OtherDOCTOR'S LICENCE NUMBER
CADC23316OtherDOCTOR'S LICENCE NUMBER