Provider Demographics
NPI:1093887440
Name:MATTHEWS, KEVIN CHARLES (LO)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:CHARLES
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
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Mailing Address - Street 1:12315 JUDSON RD
Mailing Address - Street 2:#206
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3277
Mailing Address - Country:US
Mailing Address - Phone:210-657-8100
Mailing Address - Fax:210-657-8105
Practice Address - Street 1:12315 JUDSON RD
Practice Address - Street 2:#206
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3277
Practice Address - Country:US
Practice Address - Phone:210-657-8100
Practice Address - Fax:210-657-8105
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-12-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TX558222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5945340001Medicare NSC