Provider Demographics
NPI:1902948185
Name:MATA, JUAN C (PT)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:C
Last Name:MATA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5210 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-2701
Mailing Address - Country:US
Mailing Address - Phone:956-686-4646
Mailing Address - Fax:956-631-7024
Practice Address - Street 1:5210 N 10TH ST
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-2701
Practice Address - Country:US
Practice Address - Phone:956-686-4646
Practice Address - Fax:956-631-7024
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1023703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0877482-01Medicaid
TX0877482-01Medicaid