Provider Demographics
NPI:1780228205
Name:CUELLAR, MATTHEW R
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:CUELLAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 COMSTOCK RD
Mailing Address - Street 2:
Mailing Address - City:GRANT TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48032-2014
Mailing Address - Country:US
Mailing Address - Phone:810-990-4747
Mailing Address - Fax:
Practice Address - Street 1:3111 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8127
Practice Address - Country:US
Practice Address - Phone:810-985-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC460589755437373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist