Provider Demographics
NPI:1477600641
Name:WISE, MATTHEW JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOHN
Last Name:WISE
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 1:14324 S OUTER 40
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5710
Mailing Address - Country:US
Mailing Address - Phone:314-208-8858
Mailing Address - Fax:314-205-1508
Practice Address - Street 1:190 SPRING DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-3255
Practice Address - Country:US
Practice Address - Phone:636-946-0799
Practice Address - Fax:314-205-1508
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004017456111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor