Provider Demographics
NPI:1194955484
Name:MATTHEWS CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:MATTHEWS CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ENDRE
Authorized Official - Middle Name:DEJUAN
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-366-9005
Mailing Address - Street 1:4515 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-6017
Mailing Address - Country:US
Mailing Address - Phone:601-366-9005
Mailing Address - Fax:
Practice Address - Street 1:4515 OFFICE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206
Practice Address - Country:US
Practice Address - Phone:601-366-9005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1015111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125438Medicaid
MS00125438Medicaid