Provider Demographics
NPI:1275562126
Name:MATISONS ORTHOTICS-PROSTHETICS, LLC
Entity Type:Organization
Organization Name:MATISONS ORTHOTICS-PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MATISONS
Authorized Official - Suffix:
Authorized Official - Credentials:CPO, LPO
Authorized Official - Phone:361-854-5200
Mailing Address - Street 1:3560 S ALAMEDA ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-1700
Mailing Address - Country:US
Mailing Address - Phone:361-854-5200
Mailing Address - Fax:361-854-7626
Practice Address - Street 1:3560 S ALAMEDA ST
Practice Address - Street 2:SUITE 2
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1700
Practice Address - Country:US
Practice Address - Phone:361-854-5200
Practice Address - Fax:361-854-7626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101091335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1534067-01Medicaid
TX4570390001Medicare ID - Type Unspecified