Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 5261-12 | WI |
NPI | 1003450644 |
---|---|
Provider Name | Mitchell Matthews |
First Address | Oak Brook, IL 60523-1266 |
Second Address | Hales Corners, WI 53130-1332 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2019 |
Last Update Date | 06/11/2019 |