Healthcare Provider Details

I. General information

NPI: 1417866294
Provider Name (Legal Business Name): MATTHEW KERN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2026
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42104 N VENTURE DR # B-105
PHOENIX AZ
85086-3823
US

IV. Provider business mailing address

42104 N VENTURE DR # B-105
PHOENIX AZ
85086-3823
US

V. Phone/Fax

Practice location:
  • Phone: 623-239-2615
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-08509T
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: