Provider Demographics
NPI:1588709315
Name:MATTLAGE, MICHAEL HENRY (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:HENRY
Last Name:MATTLAGE
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 1:4734 W WACO DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-7016
Mailing Address - Country:US
Mailing Address - Phone:254-772-2773
Mailing Address - Fax:254-772-2430
Practice Address - Street 1:4734 W WACO DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-7016
Practice Address - Country:US
Practice Address - Phone:254-772-2773
Practice Address - Fax:254-772-2430
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5985111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor