Provider Demographics
NPI:1235429101
Name:MARINE, MATTHEW K (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:K
Last Name:MARINE
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 1:109A S CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-1237
Mailing Address - Country:US
Mailing Address - Phone:715-539-9797
Mailing Address - Fax:715-539-9098
Practice Address - Street 1:109A S CENTER AVE
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-1237
Practice Address - Country:US
Practice Address - Phone:715-539-9797
Practice Address - Fax:715-539-9098
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-011906111N00000X
WI5177-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5177-12OtherSTATE LICENSE
WIK400325532Medicare UPIN