Provider Demographics
NPI:1366404568
Name:MATEJKA, GLEN T (DN DC DACBN CCN)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:T
Last Name:MATEJKA
Suffix:
Gender:M
Credentials:DN DC DACBN CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7105 VIRGINIA RD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7985
Mailing Address - Country:US
Mailing Address - Phone:815-455-4500
Mailing Address - Fax:815-455-4529
Practice Address - Street 1:7105 VIRGINIA RD
Practice Address - Street 2:SUITE 15
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7985
Practice Address - Country:US
Practice Address - Phone:815-455-4500
Practice Address - Fax:815-455-4529
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007434111N00000X
IL164003999111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05605168OtherBCBS IL
U48742Medicare UPIN
IL341520Medicare ID - Type Unspecified