Provider Demographics
NPI:1689809477
Name:DEMATTEO, TINA M (L AC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:DEMATTEO
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 W GREENLEAF AVE
Mailing Address - Street 2:2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-5099
Mailing Address - Country:US
Mailing Address - Phone:773-865-8462
Mailing Address - Fax:
Practice Address - Street 1:1219 W GREENLEAF AVE
Practice Address - Street 2:2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-5099
Practice Address - Country:US
Practice Address - Phone:773-865-8462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-21
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000571171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist