MEDICARE: LEONIDA MATA HYMAN

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	3747A0650X	Attendant Care Provider

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B6150363	OTHER	CA	DRIVER LICENSE

General Provider Information

NPI Number	:	1598385502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEONIDA MATA HYMAN

Provider Business Mailing Address
First Line	:	6103 POTOMAC ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92139-1730
Country	:	US
Telephone Number	:	619-802-8879
Fax Number	:

Provider Business Practice Location Address
First Line	:	6103 POTOMAC ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92139-1730
Country	:	US
Telephone Number	:	619-802-8879
Fax Number	:

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

Provider Enumeration Date	:	04/20/2020
Last Update Date	:	04/20/2020

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