Healthcare Provider Details

I. General information

NPI: 1215011044
Provider Name (Legal Business Name): MATTHEW AUGUST MAKI D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 CEDAR HILLS DR
CANNON FALLS MN
55009-4253
US

IV. Provider business mailing address

6505 CEDAR HILLS DR
CANNON FALLS MN
55009-4253
US

V. Phone/Fax

Practice location:
  • Phone: 507-263-3925
  • Fax: 507-263-5065
Mailing address:
  • Phone: 507-263-3925
  • Fax: 507-263-5065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number4074
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: