Provider Demographics
NPI:1689820946
Name:WYANDOT CHIROPRACTIC & FITNESS INC.
Entity Type:Organization
Organization Name:WYANDOT CHIROPRACTIC & FITNESS INC.
Other - Org Name:DR. MATTHEW E THIEL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:THIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-294-3489
Mailing Address - Street 1:109 HOUPT DR
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-9201
Mailing Address - Country:US
Mailing Address - Phone:419-294-3489
Mailing Address - Fax:419-294-2791
Practice Address - Street 1:109 HOUPT DR
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-9201
Practice Address - Country:US
Practice Address - Phone:419-294-3489
Practice Address - Fax:419-294-2791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1102111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000121332OtherANTHEM
OH2795088OtherMEDICAID (INDIVIDUAL)
OH$$$$$$$$$OtherSOCIAL SECURITY NUMBER
OH1821004052OtherNPI (INDIVIDUAL)
OH273645910002OtherMEDICAL MUTUAL OF OHIO
OH2882911OtherMEDICAID (GROUP)
OH5840453OtherOLD AETNA
OH273645910OtherSOCIAL SECURITY NUMBER
OH=========OtherTAX ID
OH2795088OtherMEDICAID (INDIVIDUAL)
OH1821004052OtherNPI (INDIVIDUAL)