Healthcare Provider Details

I. General information

NPI: 1366475212
Provider Name (Legal Business Name): MARK MANTEUFFEL D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26672 VAN DYKE AVE
CENTER LINE MI
48015-1222
US

IV. Provider business mailing address

26672 VAN DYKE AVE
CENTER LINE MI
48015-1222
US

V. Phone/Fax

Practice location:
  • Phone: 586-756-7670
  • Fax: 586-756-8279
Mailing address:
  • Phone: 586-756-7670
  • Fax: 586-756-8279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301002969
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: