Provider Demographics
NPI:1316392772
Name:TANNEBERG, MATTHEW (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:TANNEBERG
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 1:3520 E INDIAN SCHOOL RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-5156
Mailing Address - Country:US
Mailing Address - Phone:602-954-9444
Mailing Address - Fax:602-954-1248
Practice Address - Street 1:3520 E INDIAN SCHOOL RD
Practice Address - Street 2:SUITE C
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-5156
Practice Address - Country:US
Practice Address - Phone:602-954-9444
Practice Address - Fax:602-954-1248
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8454111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor