Provider Demographics
NPI:1396141784
Name:MATTS PLACE
Entity type:Organization
Organization Name:MATTS PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:SHERLENE
Authorized Official - Middle Name:T
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-599-8333
Mailing Address - Street 1:190 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-2814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-2814
Practice Address - Country:US
Practice Address - Phone:801-599-8333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE LONG SKILLS FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center