Provider Demographics
NPI:1417021692
Name:ELLERBROCK, MATTHEW P (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:ELLERBROCK
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 1:120 N MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BLUFFTON
Mailing Address - State:OH
Mailing Address - Zip Code:45817-1201
Mailing Address - Country:US
Mailing Address - Phone:419-358-2222
Mailing Address - Fax:419-932-6950
Practice Address - Street 1:120 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:BLUFFTON
Practice Address - State:OH
Practice Address - Zip Code:45817-0205
Practice Address - Country:US
Practice Address - Phone:419-358-2222
Practice Address - Fax:419-932-6950
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2927111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2149160Medicaid
OHH391111Medicare PIN
OH31169784200OtherBWC