Healthcare Provider Details

I. General information

NPI: 1023315090
Provider Name (Legal Business Name): MATTHEW B DEWILD RN, LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2011
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 LINCOLN RD
BETTENDORF IA
52722-4141
US

IV. Provider business mailing address

736 FEDERAL ST APT 1205
DAVENPORT IA
52803-5751
US

V. Phone/Fax

Practice location:
  • Phone: 563-484-0550
  • Fax:
Mailing address:
  • Phone: 563-940-1299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number090478
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number090478
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number006683
License Number StateIA
# 4
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number090478
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: