Provider Demographics
NPI:1609956127
Name:HERRES, MATT T (DC)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:T
Last Name:HERRES
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 1:7007 BURDEN BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-9185
Mailing Address - Country:US
Mailing Address - Phone:509-543-1123
Mailing Address - Fax:509-543-6851
Practice Address - Street 1:7007 BURDEN BLVD STE 104
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-9185
Practice Address - Country:US
Practice Address - Phone:509-543-1123
Practice Address - Fax:509-543-6851
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002819111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1386791523Medicare PIN
WAU40553Medicare UPIN
WA000304799Medicare ID - Type Unspecified