Provider Demographics
NPI:1487872321
Name:DALTON, MATTHEW JOSEPH (LMT, BS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:DALTON
Suffix:
Gender:M
Credentials:LMT, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 FAIRMONT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-3418
Mailing Address - Country:US
Mailing Address - Phone:304-368-9373
Mailing Address - Fax:
Practice Address - Street 1:2618 FAIRMONT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-3418
Practice Address - Country:US
Practice Address - Phone:304-368-9373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19980191225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist