Provider Demographics
NPI:1902994254
Name:MATACIO, CORY T (MPT)
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:T
Last Name:MATACIO
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 FIREFLY LANE
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558
Mailing Address - Country:US
Mailing Address - Phone:707-226-6020
Mailing Address - Fax:
Practice Address - Street 1:1103 TRANCAS STREET
Practice Address - Street 2:NAPA VALLEY PHYSICAL THERAPY CENTER
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558
Practice Address - Country:US
Practice Address - Phone:707-224-3131
Practice Address - Fax:707-224-2356
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 32349225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT323490Medicare ID - Type Unspecified