MEDICARE: DR. MATTHEW LEE DAVIDSON D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NS0005X	Sports Physician Chiropractor	2011012876	MO

General Provider Information

NPI Number	:	1255624508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW LEE DAVIDSON D.C.

Provider Business Mailing Address
First Line	:	1809 HERITAGE HILLS CENTER DRIVE
Second Line	:
City	:	WASHINGTON
State	:	MO
Zip	:	43090-4624
Country	:	US
Telephone Number	:	636-239-5252
Fax Number	:	636-239-4499

Provider Business Practice Location Address
First Line	:	1809 HERITAGE HILLS DR
Second Line	:
City	:	WASHINGTON
State	:	MO
Zip	:	63090-4624
Country	:	US
Telephone Number	:	636-239-5252
Fax Number	:	636-239-4499

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2011
Last Update Date	:	04/17/2017

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