Provider Demographics
NPI:1588624936
Name:AULT, MATT A (DC)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:A
Last Name:AULT
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 1:3328 PRINCETON ROAD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45011-5390
Mailing Address - Country:US
Mailing Address - Phone:513-887-9400
Mailing Address - Fax:513-887-7512
Practice Address - Street 1:3328 PRINCETON ROAD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45011-5390
Practice Address - Country:US
Practice Address - Phone:513-887-9400
Practice Address - Fax:513-887-7512
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3195111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0903688Medicaid
OHAU9266261Medicare PIN
OH0903688Medicaid