Provider Demographics
NPI:1922351626
Name:MATHIS, JUSTIN HUGH (DC)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:HUGH
Last Name:MATHIS
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 1:142 VINE ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-7472
Mailing Address - Country:US
Mailing Address - Phone:270-527-0000
Mailing Address - Fax:
Practice Address - Street 1:142 VINE ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-7472
Practice Address - Country:US
Practice Address - Phone:270-527-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5365111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor