Matt Childs

Primary specialty

Supports Brokerage AgencyTaxonomy code 251X00000X

License

1031895 Issued in WA

Practice address

1315 11TH CT SW
North Bend, WA 98045-7989

Phone

(812) 251-6639

NPI assigned

Jan 8, 2021

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1610064000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1610064000000",
    "number": "1134717747",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1315 11TH CT SW",
            "city": "NORTH BEND",
            "state": "WA",
            "postal_code": "980457989",
            "telephone_number": "812-251-6639"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1315 11TH CT SW",
            "city": "NORTH BEND",
            "state": "WA",
            "postal_code": "980457989",
            "telephone_number": "812-251-6639"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CHILDS",
        "first_name": "MATT",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2021-01-08",
        "last_updated": "2021-01-08",
        "certification_date": "2021-01-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "251X00000X",
            "taxonomy_group": "",
            "desc": "Supports Brokerage",
            "state": "WA",
            "license": "1031895",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "INSURANCE LICENSE NUMBER",
            "identifier": "1031895",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NATIONAL PRODUCER NUMBER",
            "identifier": "19306485",
            "state": null
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "CITRIX",
            "affiliation": "N",
            "endpointDescription": "secure portal",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "1315 11th Ct SW",
            "city": "North Bend",
            "state": "WA",
            "country_code": "US",
            "postal_code": "980457989",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Supports Brokerage Agency in North Bend, WA
• Providers in North Bend, WA by specialty
• Supports Brokerage Agency in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 8, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.