1497809495 NPI number — JERRY A MANTONYA

Table of content: (NPI 1497809495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497809495 NPI number — JERRY A MANTONYA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JERRY A MANTONYA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MANTONYA CHIROPRACTIC CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497809495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
919 N 21ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43055-2919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-366-6601
Provider Business Mailing Address Fax Number:
740-366-6286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
919 N 21ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43055-2919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-366-6601
Provider Business Practice Location Address Fax Number:
740-366-6286
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANTONYA
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CLINIC OWNER-DIRECTOR
Authorized Official Telephone Number:
740-366-6601

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  451 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: 870 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 3023 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 3567 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 3530 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000160597 . This is a "ANTHEM BC BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0112381 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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