Healthcare Provider Details

I. General information

NPI: 1003814229
Provider Name (Legal Business Name): HARRY B. MATOSSIAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 HOSPITAL DR
UKIAH CA
95482-4560
US

IV. Provider business mailing address

234 HOSPITAL DR SUITE A
UKIAH CA
95482-4560
US

V. Phone/Fax

Practice location:
  • Phone: 707-462-3190
  • Fax: 707-462-4647
Mailing address:
  • Phone: 707-462-3190
  • Fax: 707-462-4647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1100514
License Number StateCA

VIII. Authorized Official

Name: DR. HARRY BERJ MATOSSIAN
Title or Position: OWNER
Credential: M.D.
Phone: 707-462-3190