Provider Demographics
NPI:1275675316
Name:MATT NIRSCHL D C LLC
Entity Type:Organization
Organization Name:MATT NIRSCHL D C LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:R
Authorized Official - Last Name:NIRSCHL
Authorized Official - Suffix:
Authorized Official - Credentials:CH
Authorized Official - Phone:386-672-6565
Mailing Address - Street 1:53 NORTH OLD KINGS RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5176
Mailing Address - Country:US
Mailing Address - Phone:386-672-6565
Mailing Address - Fax:
Practice Address - Street 1:53 NORTH OLD KINGS RD
Practice Address - Street 2:SUITE C
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5176
Practice Address - Country:US
Practice Address - Phone:386-672-6565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8831111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL76138OtherBLUE CROSS BLUE SHIELD
FLAA698Medicare PIN
FLV11268Medicare UPIN