Healthcare Provider Details

I. General information

NPI: 1689820946
Provider Name (Legal Business Name): WYANDOT CHIROPRACTIC & FITNESS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 05/21/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 HOUPT DR
UPPER SANDUSKY OH
43351-9201
US

IV. Provider business mailing address

109 HOUPT DR
UPPER SANDUSKY OH
43351-9201
US

V. Phone/Fax

Practice location:
  • Phone: 419-294-3489
  • Fax: 419-294-2791
Mailing address:
  • Phone: 419-294-3489
  • Fax: 419-294-2791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1102
License Number StateOH

VIII. Authorized Official

Name: DR. MATTHEW EUGENE THIEL
Title or Position: DOCTOR OF CHIROPRACTIC
Credential: DC
Phone: 419-294-3489