Provider Demographics
NPI:1437261146
Name:REILLY, MATTHEW J (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:REILLY
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:PO BOX 186
Mailing Address - Street 2:
Mailing Address - City:ILWACO
Mailing Address - State:WA
Mailing Address - Zip Code:98624-0186
Mailing Address - Country:US
Mailing Address - Phone:360-642-2474
Mailing Address - Fax:360-642-2363
Practice Address - Street 1:167 1ST. AVE. N.
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624
Practice Address - Country:US
Practice Address - Phone:360-642-2474
Practice Address - Fax:360-642-2363
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034693111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZV00917Medicare UPIN
AZ83152Medicare PIN