Provider Demographics
NPI:1982073235
Name:CHYMIYMATTYMD LLC
Entity Type:Organization
Organization Name:CHYMIYMATTYMD LLC
Other - Org Name:PACIFICA MEDICINE AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:MATTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-979-0569
Mailing Address - Street 1:PO BOX 2940
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-2940
Mailing Address - Country:US
Mailing Address - Phone:360-979-0569
Mailing Address - Fax:877-805-9505
Practice Address - Street 1:19980 10TH AVE NE STE 202
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-6322
Practice Address - Country:US
Practice Address - Phone:360-979-0569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041619207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1740224880Medicare PIN
WA1871543900Medicare PIN