Provider Demographics
NPI:1073134177
Name:MCCLELLAN, MATTHEW BRUCE (CPO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRUCE
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8414
Mailing Address - Country:US
Mailing Address - Phone:903-592-6574
Mailing Address - Fax:903-595-3862
Practice Address - Street 1:1122 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8414
Practice Address - Country:US
Practice Address - Phone:903-592-6574
Practice Address - Fax:903-595-3862
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2047222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist