MEDICARE: MAT VENTURES LLC

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	207QA0401X	Addiction Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1467089607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAT VENTURES LLC

Provider Business Mailing Address
First Line	:	PO BOX 639
Second Line	:
City	:	DRAPER
State	:	UT
Zip	:	84020-0601
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8388 S WASATCH BLVD
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-6075
Country	:	US
Telephone Number	:	801-558-6564
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	COREY MARKISICH
Credential	:
Telephone Number	:	801-558-6564

Provider Enumeration Date	:	03/26/2020
Last Update Date	:	12/17/2020

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