Healthcare Provider Details

I. General information

NPI: 1265185318
Provider Name (Legal Business Name): PHILLIP LEE MATTOX
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2022
Last Update Date: 01/29/2022
Certification Date: 01/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1416 W 4TH ST
WATERLOO IA
50702-2908
US

IV. Provider business mailing address

1416 W 4TH ST
WATERLOO IA
50702-2908
US

V. Phone/Fax

Practice location:
  • Phone: 319-232-7113
  • Fax: 319-232-6843
Mailing address:
  • Phone: 319-232-7113
  • Fax: 319-232-6843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number079082
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: