Provider Demographics
NPI:1326482233
Name:SAFARIK, MATTHEW S (LAC, CMT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:SAFARIK
Suffix:
Gender:M
Credentials:LAC, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 WICKLOW WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-3666
Mailing Address - Country:US
Mailing Address - Phone:310-991-9797
Mailing Address - Fax:
Practice Address - Street 1:6314 ODANA RD STE 22
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1194
Practice Address - Country:US
Practice Address - Phone:310-991-9797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 15120171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist