Healthcare Provider Details

I. General information

NPI: 1831684901
Provider Name (Legal Business Name): EVA MARIA I MATUTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6050 TRESTLE ST
CRESTVIEW FL
32536
US

IV. Provider business mailing address

6050 TRESTLE ST
CRESTVIEW FL
32536-4379
US

V. Phone/Fax

Practice location:
  • Phone: 910-528-0612
  • Fax:
Mailing address:
  • Phone: 910-528-0612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: