Healthcare Provider Details

I. General information

NPI: 1386042224
Provider Name (Legal Business Name): ALBERT MATHEW I RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4259 S SQUIRES LN
GILBERT AZ
85297-1206
US

IV. Provider business mailing address

4259 S SQUIRES LN
GILBERT AZ
85297-1206
US

V. Phone/Fax

Practice location:
  • Phone: 480-248-9840
  • Fax:
Mailing address:
  • Phone: 480-248-9840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279S1500X
TaxonomySNF/Subacute Care Registered Respiratory Therapist
License Number9746
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: