Healthcare Provider Details

I. General information

NPI: 1578951851
Provider Name (Legal Business Name): MATTHEW WATSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 N ALEXANDRIA AVE
LOS ANGELES CA
90027-5203
US

IV. Provider business mailing address

320 W VALENCIA AVE UNIT 102
BURBANK CA
91506-3383
US

V. Phone/Fax

Practice location:
  • Phone: 323-660-1800
  • Fax:
Mailing address:
  • Phone: 818-636-8276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8446
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: