Provider Demographics
NPI:1689165581
Name:MATULICH, SKYLAR JAMES (LMT)
Entity Type:Individual
Prefix:
First Name:SKYLAR
Middle Name:JAMES
Last Name:MATULICH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:SKYLAR
Other - Middle Name:JAMES
Other - Last Name:MATULICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:83 KEENE RD
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-5006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:83 KEENE RD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-5006
Practice Address - Country:US
Practice Address - Phone:509-731-1461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60665508225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist