Healthcare Provider Details

I. General information

NPI: 1164143020
Provider Name (Legal Business Name): AMATALLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2022
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W 6TH ST
CORONA CA
92882-3301
US

IV. Provider business mailing address

222 W 6TH ST
CORONA CA
92882-3301
US

V. Phone/Fax

Practice location:
  • Phone: 909-379-9237
  • Fax: 888-507-7087
Mailing address:
  • Phone: 909-379-9237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MASON MATTHEW TERRY
Title or Position: OFFICE MANAGER
Credential:
Phone: 909-379-9237