Provider Demographics
NPI:1104193812
Name:DEVREUGD, MATT (DC)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:
Last Name:DEVREUGD
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 1:6411 BELLA VISTA DR NE
Mailing Address - Street 2:STE #2
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-7869
Mailing Address - Country:US
Mailing Address - Phone:616-874-7255
Mailing Address - Fax:616-874-7196
Practice Address - Street 1:6411 BELLA VISTA DR NE
Practice Address - Street 2:STE #2
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-7869
Practice Address - Country:US
Practice Address - Phone:616-874-7255
Practice Address - Fax:616-874-7196
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009861111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P04060OtherMEDICARE PTAN
MI0F38212OtherBCBSM PIN