Provider Demographics
NPI:1780690446
Name:VERSTRAETE, MATTHEW AUGUSTINE (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:AUGUSTINE
Last Name:VERSTRAETE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2123
Mailing Address - Country:US
Mailing Address - Phone:505-326-5475
Mailing Address - Fax:505-326-5476
Practice Address - Street 1:2130 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2123
Practice Address - Country:US
Practice Address - Phone:505-326-5475
Practice Address - Fax:505-326-5476
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM886111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2670672Medicare ID - Type Unspecified