Provider Demographics
NPI:1336369842
Name:MATA PHYSICAL THERAPY CLINIC
Entity Type:Organization
Organization Name:MATA PHYSICAL THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:C
Authorized Official - Last Name:MATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-686-4646
Mailing Address - Street 1:PO BOX 720267
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-0267
Mailing Address - Country:US
Mailing Address - Phone:956-686-4646
Mailing Address - Fax:
Practice Address - Street 1:5210 N 10TH ST
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-2701
Practice Address - Country:US
Practice Address - Phone:956-686-4646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1023703261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX087748201Medicaid
TX650529Medicare PIN