=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093265118
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALIA MATTEO ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2016
-----------------------------------------------------
Last Update Date | 10/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 BARNARD DR
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92056-3820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-757-2121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1616 S PACIFIC ST APT E
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92054-5830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-522-2692
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2000018448
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------