Provider Demographics
NPI:1659444792
Name:MATOS, SALATHIEL E (PA)
Entity Type:Individual
Prefix:
First Name:SALATHIEL
Middle Name:E
Last Name:MATOS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 E GREEN ST
Mailing Address - Street 2:108
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2401
Mailing Address - Country:US
Mailing Address - Phone:626-449-3830
Mailing Address - Fax:
Practice Address - Street 1:960 E GREEN ST
Practice Address - Street 2:108
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2401
Practice Address - Country:US
Practice Address - Phone:626-449-3830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15323174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist