MEDICARE: MATTHEW HERNANDEZ CSW

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	172V00000X	Community Health Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639486178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW HERNANDEZ CSW

Provider Business Mailing Address
First Line	:	PO BOX 518
Second Line	:
City	:	LOS LUNAS
State	:	NM
Zip	:	87031-0518
Country	:	US
Telephone Number	:	505-865-3350
Fax Number	:	505-865-4739

Provider Business Practice Location Address
First Line	:	4011 BARBARA LOOP SE STE 207
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-1041
Country	:	US
Telephone Number	:	505-865-3350
Fax Number	:	505-865-4739

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

Provider Enumeration Date	:	09/03/2010
Last Update Date	:	09/03/2010

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