Healthcare Provider Details

I. General information

NPI: 1659078921
Provider Name (Legal Business Name): BENJAMIN MATACHE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22366 N 68TH DR
GLENDALE AZ
85310-5239
US

IV. Provider business mailing address

22366 N 68TH DR
GLENDALE AZ
85310-5239
US

V. Phone/Fax

Practice location:
  • Phone: 482-745-9226
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number256678
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: