Provider Demographics
NPI:1952909517
Name:LOVE, MATAYAH
Entity type:Individual
Prefix:
First Name:MATAYAH
Middle Name:
Last Name:LOVE
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 1:5833 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-3840
Mailing Address - Country:US
Mailing Address - Phone:773-970-1636
Mailing Address - Fax:
Practice Address - Street 1:5833 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-3840
Practice Address - Country:US
Practice Address - Phone:773-970-1636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier