Healthcare Provider Details

I. General information

NPI: 1982367652
Provider Name (Legal Business Name): KRISTINE MATLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRISTA MATLOCK

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 ELM ST
SOUR LAKE TX
77659-2839
US

IV. Provider business mailing address

545 ELM ST
SOUR LAKE TX
77659-2839
US

V. Phone/Fax

Practice location:
  • Phone: 432-215-0636
  • Fax:
Mailing address:
  • Phone: 432-215-0636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: