Provider Demographics
NPI:1538669478
Name:BOETCHER, MATTHEW STEVEN (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:STEVEN
Last Name:BOETCHER
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 1:12415 JERRY PATH
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-9201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19285 SW MARTINAZZI AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-6352
Practice Address - Country:US
Practice Address - Phone:651-336-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5891111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor