# LEODEZ

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** B MATA LLC
- **Other names:** Centro Medico San Lucas
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1255933115
- **Legal business name:** B MATA LLC
- **Authorized official:** DR. BYRON OSWALDO MATA MD (OWNER)
- **Authorized official phone:** (786) 427-4450

## Contact information

- **Practice address:** 4292 CHAMBLEE TUCKER RD, TUCKER, GA 30084-2103
- **Practice address phone:** (770) 718-1517
- **Mailing address:** 3899 GRASSLAND LOOP, LAKE MARY, FL 32746-4120
- **Mailing address phone:** (407) 394-2645

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207QA0505X | Adult Medicine Physician | — | — | — |
| 207QG0300X | Geriatric Medicine (Family Medicine) Physician | — | — | — |
| 208D00000X | General Practice Physician | — | — | Yes |

## Other

- **Enumeration date:** 11/14/2020
- **Last updated:** 11/14/2020