Provider Demographics
NPI:1720010523
Name:MATTIS CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:MATTIS CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:MATTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-815-2221
Mailing Address - Street 1:1 PROMENADE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-7050
Mailing Address - Country:US
Mailing Address - Phone:843-815-2221
Mailing Address - Fax:843-815-2761
Practice Address - Street 1:1 PROMENADE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-7050
Practice Address - Country:US
Practice Address - Phone:843-815-2221
Practice Address - Fax:843-815-2761
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MATTIS CHIROPRACTIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-06
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2397111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8564Medicare PIN
SCU805898564Medicare UPIN