Healthcare Provider Details

I. General information

NPI: 1366785545
Provider Name (Legal Business Name): ESTRELLA MATOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 04/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 S MAIN AVE
SCRANTON PA
18504-2749
US

IV. Provider business mailing address

930 S MAIN AVE
SCRANTON PA
18504-2749
US

V. Phone/Fax

Practice location:
  • Phone: 570-909-9767
  • Fax: 570-909-9732
Mailing address:
  • Phone: 570-909-9767
  • Fax: 570-909-9732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: