Provider Demographics
NPI:1356097810
Name:MATA RESIDENTIAL CARE
Entity Type:Organization
Organization Name:MATA RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEAN CLAUDE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATABARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-549-1661
Mailing Address - Street 1:3809 S 64TH LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-0131
Mailing Address - Country:US
Mailing Address - Phone:602-549-1661
Mailing Address - Fax:833-467-1001
Practice Address - Street 1:3809 S 64TH LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043-0131
Practice Address - Country:US
Practice Address - Phone:602-549-1661
Practice Address - Fax:833-467-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health