=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528256583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY J MATTHEWS B.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2007
-----------------------------------------------------
Last Update Date | 10/04/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13055 W MCDOWELL RD. SUITE G-107
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-640-9819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16908 W WEYMOUTH RD
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85374-0840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-640-9819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 0788
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------