Provider Demographics
NPI:1073970521
Name:BLACKMON, MATTHEW (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:BLACKMON
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 1:219 E IRELAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-2653
Mailing Address - Country:US
Mailing Address - Phone:574-291-1000
Mailing Address - Fax:
Practice Address - Street 1:204 LEGACY PLZ W
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5285
Practice Address - Country:US
Practice Address - Phone:219-476-7246
Practice Address - Fax:219-476-1713
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-27
Last Update Date:2018-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002885A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor