Provider Demographics
NPI:1578617056
Name:MATTINGLY CHIROPRACTIC
Entity Type:Organization
Organization Name:MATTINGLY CHIROPRACTIC
Other - Org Name:DR DUSTAN J MATTINGLY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRODUCTION MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:FREELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-352-3345
Mailing Address - Street 1:6411 CHIPPEWA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-2104
Mailing Address - Country:US
Mailing Address - Phone:314-352-3345
Mailing Address - Fax:314-352-3460
Practice Address - Street 1:6411 CHIPPEWA ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-2104
Practice Address - Country:US
Practice Address - Phone:314-352-3345
Practice Address - Fax:314-352-3460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003002102111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU47403Medicare UPIN