Healthcare Provider Details

I. General information

NPI: 1790442754
Provider Name (Legal Business Name): DR MATTS OFFICE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N STATE ST
MARENGO IL
60152-2217
US

IV. Provider business mailing address

111 N STATE ST
MARENGO IL
60152-2217
US

V. Phone/Fax

Practice location:
  • Phone: 815-568-9900
  • Fax: 815-568-9901
Mailing address:
  • Phone: 815-568-9900
  • Fax: 815-568-9901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW BANKORD
Title or Position: PRESIDENT
Credential: DC
Phone: 815-568-9900