Provider Demographics
NPI:1649584566
Name:MAT-SU INTEGRATIVE MEDICINE
Entity Type:Organization
Organization Name:MAT-SU INTEGRATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TY
Authorized Official - Middle Name:R
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-357-2322
Mailing Address - Street 1:545 N KNIK ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7022
Mailing Address - Country:US
Mailing Address - Phone:907-357-2322
Mailing Address - Fax:
Practice Address - Street 1:545 N KNIK ST
Practice Address - Street 2:UNIT B
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7022
Practice Address - Country:US
Practice Address - Phone:907-357-2322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAK134171100000X
AKAK5699207Q00000X
AKAK5545207Q00000X
AKAK560364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's HealthGroup - Multi-Specialty