Provider Demographics
NPI:1285858498
Name:MATA, CARLOS (PT)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:MATA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7364 WHISTLEWOOD SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-8139
Mailing Address - Country:US
Mailing Address - Phone:616-583-0950
Mailing Address - Fax:
Practice Address - Street 1:709 W SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-1226
Practice Address - Country:US
Practice Address - Phone:269-792-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501001635225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236598Medicare ID - Type Unspecified