Provider Demographics
NPI:1700149580
Name:MATIACO, CAROLE L (RD, LD)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:L
Last Name:MATIACO
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15895 SW 72ND AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7977
Mailing Address - Country:US
Mailing Address - Phone:503-624-5630
Mailing Address - Fax:503-624-9149
Practice Address - Street 1:15895 SW 72ND AVE
Practice Address - Street 2:SUITE 250 BLDG B
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7977
Practice Address - Country:US
Practice Address - Phone:503-624-5630
Practice Address - Fax:503-624-9149
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000965133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5000662380Medicaid
OR5000662380Medicaid