1346317765 NPI number — MATTHEW A GOBEN, D.C. LTD

Table of content: (NPI 1346317765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346317765 NPI number — MATTHEW A GOBEN, D.C. LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATTHEW A GOBEN, D.C. LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHESTER CHIROPRACTIC CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346317765
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
987 STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTER
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62233-1654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-826-5031
Provider Business Mailing Address Fax Number:
618-826-5032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
987 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTER
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62233-1654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-826-5031
Provider Business Practice Location Address Fax Number:
618-826-5032
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOBEN
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
ADEN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
618-826-5031

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038-008691 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 419279 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 7923183 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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