Healthcare Provider Details

I. General information

NPI: 1558576702
Provider Name (Legal Business Name): KEVIN RICHARD MATTOS IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MARVIN SHIELDS BLVD CBC GULFPORT
GULFPORT MS
39501-0000
US

IV. Provider business mailing address

4674 CERNY RD
PENSACOLA FL
32526-2753
US

V. Phone/Fax

Practice location:
  • Phone: 850-341-0754
  • Fax: 228-871-2135
Mailing address:
  • Phone: 850-341-0754
  • Fax: 228-871-2135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: