Provider Demographics
NPI:1083446553
Name:IMDIEKE, MATT
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:IMDIEKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13193 COUNTY 57
Mailing Address - Street 2:
Mailing Address - City:OSAKIS
Mailing Address - State:MN
Mailing Address - Zip Code:56360-4623
Mailing Address - Country:US
Mailing Address - Phone:320-420-4562
Mailing Address - Fax:
Practice Address - Street 1:405 50TH AVE W STE 104
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-4893
Practice Address - Country:US
Practice Address - Phone:320-420-4562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2944237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist