Provider Demographics
NPI:1114278520
Name:MATHEW GROSE, D.C. CHIROPRACTIC INCORPORATION
Entity Type:Organization
Organization Name:MATHEW GROSE, D.C. CHIROPRACTIC INCORPORATION
Other - Org Name:GROSE CHIROPRACTIC SPINE AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:W
Authorized Official - Last Name:GROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:304-925-1002
Mailing Address - Street 1:4502 MACCORKLE AVE SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1835
Mailing Address - Country:US
Mailing Address - Phone:304-925-1002
Mailing Address - Fax:681-205-8382
Practice Address - Street 1:4502 MACCORKLE AVE SE
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1835
Practice Address - Country:US
Practice Address - Phone:304-925-1002
Practice Address - Fax:681-205-8382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty