Provider Demographics
NPI:1821027087
Name:VAN MATRE, GRAEME GUY (D C)
Entity Type:Individual
Prefix:
First Name:GRAEME
Middle Name:GUY
Last Name:VAN MATRE
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 732
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-0732
Mailing Address - Country:US
Mailing Address - Phone:317-496-3624
Mailing Address - Fax:317-867-1877
Practice Address - Street 1:421 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-9550
Practice Address - Country:US
Practice Address - Phone:317-496-3624
Practice Address - Fax:317-867-1877
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001960A111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN178570Medicare PIN