Provider Demographics
NPI:1265817811
Name:MATUSOV, VADYM
Entity Type:Individual
Prefix:
First Name:VADYM
Middle Name:
Last Name:MATUSOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 S ROSE ST
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95380-5531
Mailing Address - Country:US
Mailing Address - Phone:818-599-6960
Mailing Address - Fax:
Practice Address - Street 1:1904 RICHLAND AVE
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-4562
Practice Address - Country:US
Practice Address - Phone:209-300-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-24
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 235920164X00000X
CA95070466163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No164X00000XNursing Service ProvidersLicensed Vocational Nurse