Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 038007434 | IL |
N | 111NN1001X | Nutrition | 164003999 | IL |
NPI | 1366404568 |
---|---|
Provider Name | Dr. Glen T Matejka |
First Address | Crystal Lake, IL 60014-7985 |
Second Address | Crystal Lake, IL 60014-7985 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2006 |
Last Update Date | 29/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
05605168 | BCBS IL (01) | IL |
U48742 | (02) |