Provider Demographics
NPI:1972115350
Name:MATA, ALEXANDRIA (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:MATA
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:ALEX
Other - Middle Name:MATA
Other - Last Name:SHRODE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:9701 WACO AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-4454
Mailing Address - Country:US
Mailing Address - Phone:432-230-2893
Mailing Address - Fax:
Practice Address - Street 1:8207 HUDSON AVE STE D
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-2805
Practice Address - Country:US
Practice Address - Phone:432-230-2893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered