Provider Demographics
NPI:1114689841
Name:MATOSHKO CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:MATOSHKO CHIROPRACTIC CLINIC LLC
Other - Org Name:MATOSHKO CHIROPRACTIC CLINIC LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATOSHKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-795-8989
Mailing Address - Street 1:5754 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-5777
Mailing Address - Country:US
Mailing Address - Phone:586-795-8989
Mailing Address - Fax:586-999-5989
Practice Address - Street 1:5754 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-5777
Practice Address - Country:US
Practice Address - Phone:586-795-8989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-11
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2094976Medicaid
MI1689781023OtherNPI