Provider Demographics
NPI:1053454132
Name:TALLEY, MATTHEW LEVI SR
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:LEVI
Last Name:TALLEY
Suffix:SR
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 1:474 E WABASH ST
Mailing Address - Street 2:14
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5351
Mailing Address - Country:US
Mailing Address - Phone:909-888-9328
Mailing Address - Fax:
Practice Address - Street 1:474 E WABASH ST
Practice Address - Street 2:14
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5351
Practice Address - Country:US
Practice Address - Phone:909-888-9328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner