Provider Demographics
NPI:1265981161
Name:CHICO MATOS, JOSE SR
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:CHICO MATOS
Suffix:SR
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 1:2318 ACADEMY CIR W APT 201
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-8596
Mailing Address - Country:US
Mailing Address - Phone:787-310-2698
Mailing Address - Fax:
Practice Address - Street 1:2318 ACADEMY CIR W APT 201
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-8596
Practice Address - Country:US
Practice Address - Phone:787-310-2698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator