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General NPI Number Information
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NPI Number | 1265817811
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Entity Type | Individual
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Provider Name | VADYM MATUSOV
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Gender | Male
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Dates
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Enumeration Date | 07/24/2015
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Last Update Date | 07/15/2016
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Provider Practice Location Address
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Address Line | 1904 RICHLAND AVE
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City | CERES
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State | CA
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Zip | 95307-4562
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Country | US
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Telephone | 209-300-8800
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Fax |
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Provider Business Mailing Address
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Address Line | 833 S ROSE ST
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City | TURLOCK
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State | CA
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Zip | 95380-5531
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Country | US
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Telephone | 818-599-6960
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164X00000X
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Taxonomy Name | Licensed Vocational Nurse
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License Number | VN 235920
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 163WP0808X
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Taxonomy Name | Psychiatric/Mental Health Registered Nurse
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License Number | 95070466
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License Number State | CA
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