Provider Demographics
NPI:1740461755
Name:DEKRAKER, MATTHEW PETER (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PETER
Last Name:DEKRAKER
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 1:710 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-2054
Mailing Address - Country:US
Mailing Address - Phone:616-754-9172
Mailing Address - Fax:
Practice Address - Street 1:710 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2054
Practice Address - Country:US
Practice Address - Phone:616-754-9172
Practice Address - Fax:616-754-1067
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009350111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION86920Medicare PIN