Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 2018005297 | MO |
N | 111NR0400X | Rehabilitation Chiropractor | 2018005297 | MO |
Y | 111NS0005X | Chiropractic Sports Physician | 2018005297 | MO |
NPI | 1154822112 |
---|---|
Provider Name | Dr. Mathew Pilgrim |
First Address | Festus, MO 63028-2077 |
Second Address | Festus, MO 63028 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/02/2018 |
Last Update Date | 25/09/2018 |