=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962597070
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT L. MATEKEL PT, DSC, OCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9040 FITZSIMMONS DRIVE ATTN: MCHJ-PT
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-968-0780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17002 94TH AVENUE EAST
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-770-6950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 119978-2401
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------