Provider Demographics
NPI:1144608290
Name:RODERICK, MATTHEW (OMD, LAC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:RODERICK
Suffix:
Gender:M
Credentials:OMD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINDMILL PKWY APT 421
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-3395
Mailing Address - Country:US
Mailing Address - Phone:516-978-7799
Mailing Address - Fax:
Practice Address - Street 1:2675 WINDMILL PKWY APT 421
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074
Practice Address - Country:US
Practice Address - Phone:516-978-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2014171100000X
CAAC 16544171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist