Provider Demographics
NPI:1720124415
Name:VAN DYKE, MATTHEW JAY (LAC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAY
Last Name:VAN DYKE
Suffix:
Gender:M
Credentials:LAC
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 2231
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:WA
Mailing Address - Zip Code:98826-2231
Mailing Address - Country:US
Mailing Address - Phone:509-630-9784
Mailing Address - Fax:
Practice Address - Street 1:321 9TH ST
Practice Address - Street 2:# 206
Practice Address - City:LEAVENWORTH
Practice Address - State:WA
Practice Address - Zip Code:98826-1464
Practice Address - Country:US
Practice Address - Phone:509-630-9784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11415171100000X
WAAC00002999171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist