MEDICARE: SUZANNE ELIZABETH MATTESON

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	183700000X	Pharmacy Technician	197	CA

General Provider Information

NPI Number	:	1760692123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE ELIZABETH MATTESON

Provider Business Mailing Address
First Line	:	1648 AHART ST
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-2102
Country	:	US
Telephone Number	:	805-404-2756
Fax Number	:

Provider Business Practice Location Address
First Line	:	23357 PACIFIC COAST HWY
Second Line	:
City	:	MALIBU
State	:	CA
Zip	:	90265-4957
Country	:	US
Telephone Number	:	310-456-9059
Fax Number	:	310-456-6529

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/08/2007

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