Basic Information
Provider Information | |||||||||
NPI: | 1851499388 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALLIS | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.C. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2725 JAMES SANDERS BLVD | ||||||||
Address2: | SUITE A | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420018401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2705545114 | ||||||||
FaxNumber: | 2705545021 | ||||||||
Practice Location | |||||||||
Address1: | 2725 JAMES SANDERS BLVD | ||||||||
Address2: | SUITE A | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420018401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2705545114 | ||||||||
FaxNumber: | 2705545021 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 02/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 4456 | KY | Y |   | Chiropractic Providers | Chiropractor |   |
ID Information
ID | Type | State | Issuer | Description | 611375366 | 01 | KY | TAX ID | OTHER |