Provider Demographics
NPI:1720868300
Name:MATAMOROS, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MATAMOROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35490 PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-9060
Mailing Address - Country:US
Mailing Address - Phone:310-722-5709
Mailing Address - Fax:951-674-4825
Practice Address - Street 1:35490 PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-9060
Practice Address - Country:US
Practice Address - Phone:310-722-5709
Practice Address - Fax:951-674-4825
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA331800082310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility