=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407131097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLOBAL MATRIX INTERNATIONAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2011
-----------------------------------------------------
Last Update Date | 10/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6030 HWY 85 STE 202-4
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-596-0320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6030 HIGHWAY 85 STE 202-4
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-596-0320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. MARIO LANCASTER KIMBALL
-----------------------------------------------------
Credential | M-DIV
-----------------------------------------------------
Telephone | 678-596-0320
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------