Provider Demographics
NPI:1174688253
Name:MATA, OLMAN (DC)
Entity type:Individual
Prefix:
First Name:OLMAN
Middle Name:
Last Name:MATA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 W BADILLO ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723
Mailing Address - Country:US
Mailing Address - Phone:626-966-4469
Mailing Address - Fax:626-915-8929
Practice Address - Street 1:461 W BADILLO ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1834
Practice Address - Country:US
Practice Address - Phone:626-966-4469
Practice Address - Fax:626-915-8929
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22763111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC22763Medicare ID - Type Unspecified