=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043354707
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATRIX PARENT NETWROK AND RESOURCE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 94 GALLI DR SUITE C
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94949-5739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-884-3535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 94 GALLI DR SUITE C
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94949-5739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-884-3535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUITVE DIRECTOR
-----------------------------------------------------
Name | NORA THOMPSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-884-3535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------