Provider Demographics
NPI:1104198506
Name:LEARY, MATTHEW D (DC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:LEARY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16049 TUSCOLA RD
Mailing Address - Street 2:STE B
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-0824
Mailing Address - Country:US
Mailing Address - Phone:760-242-4111
Mailing Address - Fax:
Practice Address - Street 1:18564 US HIGHWAY 18
Practice Address - Street 2:SUITE 303
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2312
Practice Address - Country:US
Practice Address - Phone:760-242-4111
Practice Address - Fax:760-242-4555
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-31
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32175111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor