Provider Demographics
NPI:1306855168
Name:MATTIELLO, VINCENT T (DC)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:T
Last Name:MATTIELLO
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 1:29 BIG BUCK TRL
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-4279
Mailing Address - Country:US
Mailing Address - Phone:386-405-0652
Mailing Address - Fax:
Practice Address - Street 1:2845 ENTERPRISE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-5224
Practice Address - Country:US
Practice Address - Phone:386-668-9200
Practice Address - Fax:386-668-9200
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9167111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor