Provider Demographics
NPI:1801911011
Name:WAACK, MATTHEW LAWRENCE (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LAWRENCE
Last Name:WAACK
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 1:115 MCKINSEY DR
Mailing Address - Street 2:
Mailing Address - City:MAQUOKETA
Mailing Address - State:IA
Mailing Address - Zip Code:52060-2014
Mailing Address - Country:US
Mailing Address - Phone:563-652-6884
Mailing Address - Fax:
Practice Address - Street 1:115 MCKINSEY DR
Practice Address - Street 2:
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-2014
Practice Address - Country:US
Practice Address - Phone:563-652-6884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06673111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA13914OtherBLUE CROSS BLUE SHIELD
IA0443788Medicaid
IA13914OtherBLUE CROSS BLUE SHIELD