MEDICARE: KASSANDRA MARYCELA DE MATTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1346836301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KASSANDRA MARYCELA DE MATTA

Provider Business Mailing Address
First Line	:	4423 LONG BEACH AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90058-1922
Country	:	US
Telephone Number	:	323-360-2893
Fax Number	:

Provider Business Practice Location Address
First Line	:	4423 LONG BEACH AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90058-1922
Country	:	US
Telephone Number	:	323-360-2893
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2020
Last Update Date	:	12/14/2020

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