Provider Demographics
NPI:1942678206
Name:HARBOUR, MATTHEW LANE (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LANE
Last Name:HARBOUR
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 1:332 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541-1508
Mailing Address - Country:US
Mailing Address - Phone:304-948-5979
Mailing Address - Fax:681-233-0001
Practice Address - Street 1:332 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WV
Practice Address - Zip Code:25541-1508
Practice Address - Country:US
Practice Address - Phone:304-948-5979
Practice Address - Fax:681-233-0001
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV984111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100389900Medicaid
KY7100389900Medicaid