Provider Demographics
NPI:1619072790
Name:FENTRESS, MATTHEW WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WAYNE
Last Name:FENTRESS
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 1:840 CORBIN PARK RD
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-8424
Mailing Address - Country:US
Mailing Address - Phone:252-302-1230
Mailing Address - Fax:
Practice Address - Street 1:555 W GRANADA BLVD
Practice Address - Street 2:STE E6
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9402
Practice Address - Country:US
Practice Address - Phone:910-791-1211
Practice Address - Fax:910-791-5678
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11802111N00000X
NC3163111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC085XGOtherBLUE CROSS
NC5902673Medicaid
NC2458380Medicare ID - Type Unspecified
NC5902673Medicaid