Provider Demographics
NPI:1356797666
Name:MAT GEORGIA, LLC
Entity type:Organization
Organization Name:MAT GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:ALFONSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-212-4659
Mailing Address - Street 1:1290 KENNESTONE CIR
Mailing Address - Street 2:SUITE A112
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:335 ROSELANE ST NW
Practice Address - Street 2:SUITE 203
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7902
Practice Address - Country:US
Practice Address - Phone:818-212-4659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty