Healthcare Provider Details

I. General information

NPI: 1306855168
Provider Name (Legal Business Name): VINCENT T MATTIELLO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 ENTERPRISE RD SUITE 101
DEBARY FL
32713-5224
US

IV. Provider business mailing address

29 BIG BUCK TRL
ORMOND BEACH FL
32174-4279
US

V. Phone/Fax

Practice location:
  • Phone: 386-668-9200
  • Fax: 386-668-9200
Mailing address:
  • Phone: 386-405-0652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH9167
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: