Provider Demographics
NPI:1598916124
Name:MATSUO, SHINICHI (LAC)
Entity type:Individual
Prefix:
First Name:SHINICHI
Middle Name:
Last Name:MATSUO
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 1:4236 N CAMPBELL AVE
Mailing Address - Street 2:#3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-2827
Mailing Address - Country:US
Mailing Address - Phone:847-828-3317
Mailing Address - Fax:
Practice Address - Street 1:3322 N ASHLAND AVE
Practice Address - Street 2:#2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2109
Practice Address - Country:US
Practice Address - Phone:847-828-3317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000417171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist