Healthcare Provider Details

I. General information

NPI: 1619140340
Provider Name (Legal Business Name): MYRNA L. MATTOS R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 DEVINE STREET
COLUMBIA SC
29208-0001
US

IV. Provider business mailing address

1409 DEVINE STREET
COLUMBIA SC
29208-0001
US

V. Phone/Fax

Practice location:
  • Phone: 803-777-3658
  • Fax: 803-777-0126
Mailing address:
  • Phone: 803-777-3658
  • Fax: 803-777-0126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberR106388
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: