Provider Demographics
NPI:1902504194
Name:MATA, BRIAN JESSE
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JESSE
Last Name:MATA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12021 SOUTH WILMINGTON AVE
Mailing Address - Street 2:BUILDING 18 SUITE 300
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059
Mailing Address - Country:US
Mailing Address - Phone:424-454-6041
Mailing Address - Fax:
Practice Address - Street 1:12021 SOUTH WILMINGTON AVE
Practice Address - Street 2:BUILDING 18 SUITE 300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059
Practice Address - Country:US
Practice Address - Phone:424-454-6041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver