Provider Demographics
NPI:1215456520
Name:KERR, MATTHEW (LAC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:KERR
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5820 N KENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-3765
Mailing Address - Country:US
Mailing Address - Phone:773-456-2557
Mailing Address - Fax:
Practice Address - Street 1:216 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-6909
Practice Address - Country:US
Practice Address - Phone:312-216-2412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001053171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist