Healthcare Provider Details

I. General information

NPI: 1114852076
Provider Name (Legal Business Name): AMBROSE MATHENY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8834 MORRO RD
ATASCADERO CA
93422-3953
US

IV. Provider business mailing address

903 AMBROSIA LN
SAN LUIS OBISPO CA
93401-7848
US

V. Phone/Fax

Practice location:
  • Phone: 805-466-7827
  • Fax: 866-317-1665
Mailing address:
  • Phone: 615-454-8428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: