Provider Demographics
NPI:1598350050
Name:MATALDA, CHARLESTON
Entity Type:Individual
Prefix:
First Name:CHARLESTON
Middle Name:
Last Name:MATALDA
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 1:1208 WESTPORT BEACH WAY UNIT B
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8857
Mailing Address - Country:US
Mailing Address - Phone:701-317-5128
Mailing Address - Fax:
Practice Address - Street 1:1208 WESTPORT BEACH WAY UNIT B
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-8857
Practice Address - Country:US
Practice Address - Phone:701-317-5128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-06
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant