Provider Demographics
NPI:1275374829
Name:TARRILLION, MATTHEW GIRARD I (LMT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GIRARD
Last Name:TARRILLION
Suffix:I
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 1:1302 OLD SAINT MARYS RD
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-1242
Mailing Address - Country:US
Mailing Address - Phone:573-517-1029
Mailing Address - Fax:
Practice Address - Street 1:1302 OLD SAINT MARYS RD
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-1242
Practice Address - Country:US
Practice Address - Phone:573-517-1029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017023381225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty