Provider Demographics
NPI:1366718751
Name:MATERI CHIROPRACTIC CENTER, LLC
Entity type:Organization
Organization Name:MATERI CHIROPRACTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MATERI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:307-283-4040
Mailing Address - Street 1:207 MAIN ST
Mailing Address - Street 2:BOX 971
Mailing Address - City:SUNDANCE
Mailing Address - State:WY
Mailing Address - Zip Code:82729-0971
Mailing Address - Country:US
Mailing Address - Phone:307-283-4040
Mailing Address - Fax:307-283-4041
Practice Address - Street 1:207 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUNDANCE
Practice Address - State:WY
Practice Address - Zip Code:82729-0971
Practice Address - Country:US
Practice Address - Phone:307-283-4040
Practice Address - Fax:307-283-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY579111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW307657Medicare PIN