Healthcare Provider Details

I. General information

NPI: 1316392772
Provider Name (Legal Business Name): MATTHEW TANNEBERG DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 E INDIAN SCHOOL RD SUITE C
PHOENIX AZ
85018-5156
US

IV. Provider business mailing address

3520 E INDIAN SCHOOL RD SUITE C
PHOENIX AZ
85018-5156
US

V. Phone/Fax

Practice location:
  • Phone: 602-954-9444
  • Fax: 602-954-1248
Mailing address:
  • Phone: 602-954-9444
  • Fax: 602-954-1248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8454
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: