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General NPI Number Information
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NPI Number | 1720124415
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Entity Type | Individual
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Provider Name | MATTHEW JAY VAN DYKE L.AC.
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Gender | Male
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Dates
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Enumeration Date | 01/29/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 321 9TH ST # 206
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City | LEAVENWORTH
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State | WA
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Zip | 98826-1464
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Country | US
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Telephone | 509-630-9784
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2231
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City | LEAVENWORTH
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State | WA
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Zip | 98826-2231
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Country | US
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Telephone | 509-630-9784
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 11415
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AC00002999
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License Number State | WA
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