Provider Demographics
NPI:1235288812
Name:CARON, MATTHEW REQUA (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:REQUA
Last Name:CARON
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 1:813 BADLANDS RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7617
Mailing Address - Country:US
Mailing Address - Phone:715-381-2852
Mailing Address - Fax:
Practice Address - Street 1:490 SNELLING AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1501
Practice Address - Country:US
Practice Address - Phone:651-699-6044
Practice Address - Fax:651-699-2065
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3033111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN338028900Medicaid
350001132Medicare ID - Type Unspecified