Provider Demographics
NPI:1376643106
Name:MATHRE, DENISE P (DC)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:P
Last Name:MATHRE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:12150 INDUSTRY BLVD STE 45
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-9375
Mailing Address - Country:US
Mailing Address - Phone:209-223-4442
Mailing Address - Fax:209-231-5144
Practice Address - Street 1:12150 INDUSTRY BLVD STE 45
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-9375
Practice Address - Country:US
Practice Address - Phone:209-223-4442
Practice Address - Fax:209-231-5144
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CADC24828111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU68302Medicare UPIN
CADC248280Medicare ID - Type Unspecified