Healthcare Provider Details

I. General information

NPI: 1720284334
Provider Name (Legal Business Name): GRACE ZLAKET MATTA MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9336 E, RAINTREE DR. STE 150
SCOTTSDALE AZ
85260-7314
US

IV. Provider business mailing address

9336 E, RAINTREE DR. STE 150
SCOTTSDALE AZ
85260-7314
US

V. Phone/Fax

Practice location:
  • Phone: 480-219-5597
  • Fax: 480-219-5547
Mailing address:
  • Phone: 480-219-5597
  • Fax: 480-219-5547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number23480
License Number StateAZ

VIII. Authorized Official

Name: MRS. GRACE ZLAKET-MATTA
Title or Position: MEDICAL DIRECTOR - PRESIDENT
Credential:
Phone: 480-219-5597