Provider Demographics
NPI:1043297641
Name:CLOVER, MATTHEW B (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
Last Name:CLOVER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54957-0246
Mailing Address - Country:US
Mailing Address - Phone:920-722-7947
Mailing Address - Fax:920-722-7949
Practice Address - Street 1:1576 LYON DR
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-5069
Practice Address - Country:US
Practice Address - Phone:920-722-1744
Practice Address - Fax:920-722-7949
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4089012WI111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
V06359Medicare UPIN
WI135771Medicare ID - Type Unspecified