Healthcare Provider Details

I. General information

NPI: 1790174456
Provider Name (Legal Business Name): MATTHEW JOEL PEACOCK D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4266 STATE ST
SAGINAW MI
48603-4035
US

IV. Provider business mailing address

408 N 3RD ST
ROGERS CITY MI
49779-1309
US

V. Phone/Fax

Practice location:
  • Phone: 989-792-6702
  • Fax: 989-729-1128
Mailing address:
  • Phone: 989-734-3384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301010287
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: