Healthcare Provider Details

I. General information

NPI: 1679571822
Provider Name (Legal Business Name): DARREL THOMAS MATHIS D.C.,F.A.C.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 04/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 SW MAIN BLVD
LAKE CITY FL
32025-7050
US

IV. Provider business mailing address

279 SW MAIN BLVD
LAKE CITY FL
32025-7050
US

V. Phone/Fax

Practice location:
  • Phone: 386-752-4313
  • Fax: 386-752-8356
Mailing address:
  • Phone: 386-752-4313
  • Fax: 386-752-8356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberCH5141
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: