Healthcare Provider Details

I. General information

NPI: 1265193080
Provider Name (Legal Business Name): JUSTIN ALEXANDER MATAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 N MAIN ST STE 127
CORONA CA
92878-1440
US

IV. Provider business mailing address

140 BREEDERS CUP PL
NORCO CA
92860-5100
US

V. Phone/Fax

Practice location:
  • Phone: 951-216-3549
  • Fax: 951-419-4348
Mailing address:
  • Phone: 949-836-7487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95026056
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95026056
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: