Provider Demographics
NPI:1902985005
Name:MATTLEY, RONDA L (DC)
Entity Type:Individual
Prefix:DR
First Name:RONDA
Middle Name:L
Last Name:MATTLEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4621
Mailing Address - Country:US
Mailing Address - Phone:208-461-4227
Mailing Address - Fax:208-461-4227
Practice Address - Street 1:1004 13TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4621
Practice Address - Country:US
Practice Address - Phone:208-461-4227
Practice Address - Fax:208-461-4227
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1005111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC2979OtherBLUE CROSS OF IDAHO
ID000010141494OtherREGENCE BLUE SHIELD OF ID
ID1675019Medicare ID - Type Unspecified