Healthcare Provider Details

I. General information

NPI: 1629538194
Provider Name (Legal Business Name): GLENN P. MATNEY, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 08/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12402 INDUSTRIAL BLVD STE B1
VICTORVILLE CA
92395-5889
US

IV. Provider business mailing address

12402 INDUSTRIAL BLVD STE B1
VICTORVILLE CA
92395-5889
US

V. Phone/Fax

Practice location:
  • Phone: 760-245-9363
  • Fax: 760-245-5158
Mailing address:
  • Phone: 760-245-9363
  • Fax: 760-245-5158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GLENN PAUL MATNEY
Title or Position: PRESIDENT
Credential: MD
Phone: 760-245-9363