Provider Demographics
NPI:1568090157
Name:SPENCER, MATTHEW EARL
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EARL
Last Name:SPENCER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 N DETROIT ST STE 105
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2963
Mailing Address - Country:US
Mailing Address - Phone:937-610-4673
Mailing Address - Fax:
Practice Address - Street 1:36 N DETROIT ST STE 105
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2963
Practice Address - Country:US
Practice Address - Phone:937-610-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.160411.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse