Provider Demographics
NPI:1588896849
Name:MATRIX NETWORK MANAGEMENT LLC
Entity type:Organization
Organization Name:MATRIX NETWORK MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:FONDREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-600-1290
Mailing Address - Street 1:409 E CALIFORNIA AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-4226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 E CALIFORNIA AVE STE 210
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4226
Practice Address - Country:US
Practice Address - Phone:405-600-1290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization