Healthcare Provider Details

I. General information

NPI: 1760123640
Provider Name (Legal Business Name): MATTHEW TYLER MONACO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 W INDIANA AVE
CHESTERTON IN
46304-2350
US

IV. Provider business mailing address

PO BOX 1430
PORTAGE IN
46368-9230
US

V. Phone/Fax

Practice location:
  • Phone: 219-763-8112
  • Fax: 219-763-8937
Mailing address:
  • Phone: 219-763-8112
  • Fax: 219-764-5333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08003293A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: