Provider Demographics
NPI:1447405386
Name:DR GRAEME VAN MATRE INC
Entity Type:Organization
Organization Name:DR GRAEME VAN MATRE INC
Other - Org Name:GRAEME VAN MATRE DC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRAEME
Authorized Official - Middle Name:GUY
Authorized Official - Last Name:VAN MATRE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-496-3624
Mailing Address - Street 1:421 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-9550
Mailing Address - Country:US
Mailing Address - Phone:317-496-3624
Mailing Address - Fax:317-867-1877
Practice Address - Street 1:421 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-9550
Practice Address - Country:US
Practice Address - Phone:317-496-3624
Practice Address - Fax:317-867-1877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001960A261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6207100001Medicare PIN