Provider Demographics
NPI:1528160975
Name:KOENEN, MATTHEW C (DC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:KOENEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 WEST ST
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-2185
Mailing Address - Country:US
Mailing Address - Phone:641-236-7565
Mailing Address - Fax:
Practice Address - Street 1:933 WEST ST
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-2185
Practice Address - Country:US
Practice Address - Phone:641-236-7565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA06094111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA47072OtherWELLMARK BCBS
47072Medicare ID - Type Unspecified