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General NPI Number Information
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NPI Number | 1669642146
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Entity Type | Organization
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Legal Business Name | WAYSIDE EXIT, INC.
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Dates
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Enumeration Date | 03/11/2008
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Last Update Date | 03/10/2009
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Provider Practice Location Address
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Address Line | 2321 50TH ST SUITE A
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City | LUBBOCK
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State | TX
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Zip | 79412-2563
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Country | US
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Telephone | 806-793-9005
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Fax | 806-791-2452
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Provider Business Mailing Address
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Address Line | 2321 50TH ST SUITE A
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City | LUBBOCK
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State | TX
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Zip | 79412-2563
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Country | US
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Telephone | 806-793-9005
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Fax | 806-791-2452
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Authorized Official
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Title or Position | DOCTOR OF CHIROPRACTIC
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Name | DR. MATTHEW RICHARD ROEDER
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Credential | D.C.
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Telephone | 806-793-9005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 8858
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License Number State | TX
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