Provider Demographics
NPI:1275295198
Name:LO, MATTHEW J
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:LO
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 1:901 ELK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-8556
Mailing Address - Country:US
Mailing Address - Phone:262-364-9356
Mailing Address - Fax:
Practice Address - Street 1:901 ELK CREEK RD
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8556
Practice Address - Country:US
Practice Address - Phone:262-364-9356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver