Provider Demographics
NPI:1558686014
Name:TAVOLACCI, MATTHEW JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOHN
Last Name:TAVOLACCI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12797 FOREST HILL BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-4763
Mailing Address - Country:US
Mailing Address - Phone:561-793-5550
Mailing Address - Fax:561-793-5788
Practice Address - Street 1:12797 FOREST HILL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-4763
Practice Address - Country:US
Practice Address - Phone:561-793-5550
Practice Address - Fax:561-793-5788
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-28
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008631111N00000X
FLCH10273111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor