Provider Demographics
NPI:1902094840
Name:GRAVEL, MATTHEW D (DC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:D
Last Name:GRAVEL
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 1:333 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2582
Mailing Address - Country:US
Mailing Address - Phone:651-294-2332
Mailing Address - Fax:651-294-2333
Practice Address - Street 1:333 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2582
Practice Address - Country:US
Practice Address - Phone:651-294-2332
Practice Address - Fax:651-294-2333
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5560111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN262213271OtherGROUP TAX ID#
MN262213271OtherGROUP TAX ID#