Provider Demographics
NPI:1285123588
Name:MATTIELLO, VINCENT
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:
Last Name:MATTIELLO
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:PO BOX 280113
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-0113
Mailing Address - Country:US
Mailing Address - Phone:720-465-5467
Mailing Address - Fax:303-922-4640
Practice Address - Street 1:13924 MARQUESAS WAY APT 2302
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6020
Practice Address - Country:US
Practice Address - Phone:310-908-5820
Practice Address - Fax:303-922-4640
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic