Provider Demographics
NPI:1902038326
Name:SOUTHLAND SPINE & REHABILITATION MED CTR
Entity Type:Organization
Organization Name:SOUTHLAND SPINE & REHABILITATION MED CTR
Other - Org Name:SOUTHLAND SPINE & REHABILITATION MED CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:9512-752-5888
Mailing Address - Street 1:4354 LATHAM ST STE 100
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-1777
Mailing Address - Country:US
Mailing Address - Phone:951-275-5888
Mailing Address - Fax:951-275-5887
Practice Address - Street 1:4354 LATHAM ST STE 100
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-1777
Practice Address - Country:US
Practice Address - Phone:951-275-5888
Practice Address - Fax:951-275-5887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty