Provider Demographics
NPI:1689752750
Name:MATOUSEK CHIROPRACTIC, P.A.
Entity Type:Organization
Organization Name:MATOUSEK CHIROPRACTIC, P.A.
Other - Org Name:REAL HEALTH CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARHAE
Authorized Official - Middle Name:ANGELA
Authorized Official - Last Name:MATOUSEK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-224-0607
Mailing Address - Street 1:8901 AZTEC DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-1916
Mailing Address - Country:US
Mailing Address - Phone:952-224-0607
Mailing Address - Fax:952-224-2418
Practice Address - Street 1:8901 AZTEC DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55347-1916
Practice Address - Country:US
Practice Address - Phone:952-224-0607
Practice Address - Fax:952-224-2418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3818111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10841700Medicaid
MN10841700Medicaid
MNCO3431Medicare ID - Type Unspecified