Provider Demographics
NPI:1245373224
Name:WOOLLEY, MATTHEW MARK (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MARK
Last Name:WOOLLEY
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 1:2061 E 9400 S
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-3128
Mailing Address - Country:US
Mailing Address - Phone:801-943-8308
Mailing Address - Fax:801-438-0058
Practice Address - Street 1:2061 E 9400 S
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-3128
Practice Address - Country:US
Practice Address - Phone:801-943-8308
Practice Address - Fax:801-438-0058
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5368537-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT87039551OtherCHIROPRACTIC HEALTH PLAN
UT870395551005Medicaid