Provider Demographics
NPI:1831339498
Name:GROSE, MATHEW WALTON (DC)
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:WALTON
Last Name:GROSE
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 1:118 TAYLOR LN
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-1337
Mailing Address - Country:US
Mailing Address - Phone:043-645-6524
Mailing Address - Fax:304-645-6527
Practice Address - Street 1:118 TAYLOR LN
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-1337
Practice Address - Country:US
Practice Address - Phone:304-925-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV890111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor