Provider Demographics
NPI:1154984748
Name:PICKARD, MATTHEW RON (LMT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RON
Last Name:PICKARD
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 E RIVER RD STE B
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-8591
Mailing Address - Country:US
Mailing Address - Phone:231-744-6400
Mailing Address - Fax:231-744-6464
Practice Address - Street 1:1519 E RIVER RD STE B
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-8591
Practice Address - Country:US
Practice Address - Phone:231-744-6400
Practice Address - Fax:231-744-6464
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501009329225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7501009329OtherLICENSE