Healthcare Provider Details

I. General information

NPI: 1154618866
Provider Name (Legal Business Name): DANIEL RAYMOND MATTHIESEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12907 HIGHWAY 36
NEEDVILLE TX
77461
US

IV. Provider business mailing address

PO BOX 467
NEEDVILLE TX
77461-0467
US

V. Phone/Fax

Practice location:
  • Phone: 979-793-7570
  • Fax: 979-793-5540
Mailing address:
  • Phone: 979-793-7570
  • Fax: 979-793-5540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: