Healthcare Provider Details

I. General information

NPI: 1477600641
Provider Name (Legal Business Name): MATTHEW JOHN WISE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 SPRING DR
SAINT CHARLES MO
63303-3255
US

IV. Provider business mailing address

14324 S OUTER 40
CHESTERFIELD MO
63017-5710
US

V. Phone/Fax

Practice location:
  • Phone: 636-946-0799
  • Fax: 314-205-1508
Mailing address:
  • Phone: 314-208-8858
  • Fax: 314-205-1508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2004017456
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: