Provider Demographics
NPI:1720319817
Name:NICHOLSON, MATTHEW R (DC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:NICHOLSON
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 1:2534 HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-6625
Mailing Address - Country:US
Mailing Address - Phone:636-978-5511
Mailing Address - Fax:
Practice Address - Street 1:2534 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-6625
Practice Address - Country:US
Practice Address - Phone:636-978-5511
Practice Address - Fax:636-281-5511
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010001122111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor