Provider Demographics
NPI:1891227849
Name:ANDREOLLI, MATTHEW (MS, ATC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:ANDREOLLI
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4344 W POINT LOMA BLVD
Mailing Address - Street 2:# P
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-1183
Mailing Address - Country:US
Mailing Address - Phone:805-551-7454
Mailing Address - Fax:
Practice Address - Street 1:2000 TRIDENT WAY
Practice Address - Street 2:211
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5599
Practice Address - Country:US
Practice Address - Phone:805-551-7454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2000014222171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor