Provider Demographics
NPI:1417066515
Name:MATRIX MOBILITY & HEALTHCARE PRODUCTS, LLC
Entity Type:Organization
Organization Name:MATRIX MOBILITY & HEALTHCARE PRODUCTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNWER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHANT
Authorized Official - Middle Name:TYRONE
Authorized Official - Last Name:PAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-456-8018
Mailing Address - Street 1:125 COMMONS WAY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-7038
Mailing Address - Country:US
Mailing Address - Phone:770-456-8018
Mailing Address - Fax:678-228-1424
Practice Address - Street 1:125 COMMONS WAY
Practice Address - Street 2:SUITE 203
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-7038
Practice Address - Country:US
Practice Address - Phone:770-456-8018
Practice Address - Fax:678-228-1424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA441911409AMedicaid
GA52210310OtherBCBS
GA52210310OtherBCBS