Provider Demographics
NPI:1114259249
Name:POWELL, MATTHEW L (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:POWELL
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 1:826 HWY 90
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-2701
Mailing Address - Country:US
Mailing Address - Phone:228-467-1018
Mailing Address - Fax:228-467-4608
Practice Address - Street 1:826 HWY 90
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-2701
Practice Address - Country:US
Practice Address - Phone:228-467-1018
Practice Address - Fax:228-467-4608
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1158111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor