Provider Demographics
NPI:1912142159
Name:SHELLY, MATTHEW JOSEPH (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:SHELLY
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 1:17534 OLD JEFFERSON HWY
Mailing Address - Street 2:SUITE C2
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3978
Mailing Address - Country:US
Mailing Address - Phone:985-400-1633
Mailing Address - Fax:
Practice Address - Street 1:17534 OLD JEFFERSON HWY
Practice Address - Street 2:SUITE C2
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3978
Practice Address - Country:US
Practice Address - Phone:985-400-1633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1497111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor