Provider Demographics
NPI:1659685691
Name:MATRIX MEDICAL NETWORK OF MISSOURI, LLC
Entity Type:Organization
Organization Name:MATRIX MEDICAL NETWORK OF MISSOURI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALVAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-862-1695
Mailing Address - Street 1:9201 E MOUNTAIN VIEW #220
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5172
Mailing Address - Country:US
Mailing Address - Phone:480-862-1700
Mailing Address - Fax:877-506-4560
Practice Address - Street 1:111 W PORT PLZ STE 600
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3015
Practice Address - Country:US
Practice Address - Phone:480-862-1677
Practice Address - Fax:480-718-7643
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CARE HEALTH NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-02
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty