Provider Demographics
NPI:1134128382
Name:MATTHIAS, L. RUSSELL (DC)
Entity Type:Individual
Prefix:DR
First Name:L.
Middle Name:RUSSELL
Last Name:MATTHIAS
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 1:1050 NW SOUTH OUTER RD
Mailing Address - Street 2:STE 400
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-3064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 NW SOUTH OUTER RD
Practice Address - Street 2:SUITE 400
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-3064
Practice Address - Country:US
Practice Address - Phone:816-228-5113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2011-10-11
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
MO003788111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT42433Medicare UPIN
MO0005302AMedicare PIN