Provider Demographics
NPI:1821602392
Name:IXTA-MATUTE, JOSE ANTONIO
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
Last Name:IXTA-MATUTE
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 1:7226 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2003
Mailing Address - Country:US
Mailing Address - Phone:818-235-1414
Mailing Address - Fax:
Practice Address - Street 1:210 N CITRUS AVE
Practice Address - Street 2:1
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician