Provider Demographics
NPI:1578822862
Name:MATLOCK, CALEB CHARLES
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:CHARLES
Last Name:MATLOCK
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 1:4160 S. PECOS STE 17
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121
Mailing Address - Country:US
Mailing Address - Phone:530-921-3455
Mailing Address - Fax:
Practice Address - Street 1:4160 S. PECOS STE 17
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121
Practice Address - Country:US
Practice Address - Phone:530-921-3455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner