Provider Demographics
NPI:1477530061
Name:CRILLEY, MATTHEW (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:CRILLEY
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 1:12740 SPRUCE TREE WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8295
Mailing Address - Country:US
Mailing Address - Phone:919-570-6160
Mailing Address - Fax:919-570-6170
Practice Address - Street 1:12740 SPRUCE TREE WAY
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8295
Practice Address - Country:US
Practice Address - Phone:919-570-6160
Practice Address - Fax:919-570-6170
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2846111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790201UMedicaid
NC0846VOtherBCBS INDIVIDUAL NUMBER
NC0201UOtherBCBS GROUP NUMBER
NC890846VMedicaid
NC2454079CMedicare ID - Type UnspecifiedINDIVIDUAL NUMBER
NCU81955Medicare UPIN
NC790201UMedicaid