Provider Demographics
NPI:1285481739
Name:MATTLAURE INDUSTRIES, LLC
Entity type:Organization
Organization Name:MATTLAURE INDUSTRIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OM
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-422-1003
Mailing Address - Street 1:3319 S STATE ROAD 7 STE 113
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33449-8099
Mailing Address - Country:US
Mailing Address - Phone:561-422-1003
Mailing Address - Fax:561-422-1003
Practice Address - Street 1:3319 S STATE ROAD 7 STE 113
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33449-8099
Practice Address - Country:US
Practice Address - Phone:561-422-1003
Practice Address - Fax:561-422-1003
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANITA GARIB-SANKAR, MD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269259700Medicaid