Provider Demographics
NPI:1235449471
Name:THACKER, MATTHEW (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:THACKER
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 1:437 SPRINGFIELD ST
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-1052
Mailing Address - Country:US
Mailing Address - Phone:708-870-6161
Mailing Address - Fax:
Practice Address - Street 1:437 SPRINGFIELD ST
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-1052
Practice Address - Country:US
Practice Address - Phone:708-870-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011476111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor