Provider Demographics
NPI:1447769591
Name:MATA, JOE
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:MATA
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 1:606 OAKLAND AVE APT 212
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-2062
Mailing Address - Country:US
Mailing Address - Phone:312-962-9538
Mailing Address - Fax:
Practice Address - Street 1:606 OAKLAND AVE APT 212
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802
Practice Address - Country:US
Practice Address - Phone:312-962-9538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347E00000XTransportation ServicesTransportation Broker