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General NPI Number Information
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NPI Number | 1104375013
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Entity Type | Organization
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Legal Business Name | MATTMO OUTREACH RESIDENTIAL SERIVCES
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Dates
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Enumeration Date | 10/04/2016
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Last Update Date | 10/04/2016
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Provider Practice Location Address
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Address Line | 135 S LIBERTY ST
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City | DELAWARE
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State | OH
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Zip | 43015-2568
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Country | US
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Telephone | 804-912-4095
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Fax |
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Provider Business Mailing Address
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Address Line | 135 S LIBERTY ST
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City | DELAWARE
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State | OH
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Zip | 43015-2568
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Country | US
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Telephone | 804-912-4095
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MISS HAJAH MEMUNATU CONTEH
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Credential | BSN, RN
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Telephone | 804-912-4095
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number |
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License Number State |
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