Healthcare Provider Details

I. General information

NPI: 1164569562
Provider Name (Legal Business Name): JERRY A MANTONYA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 N HIGH ST
HEBRON OH
43025-9669
US

IV. Provider business mailing address

149 N HIGH ST
HEBRON OH
43025-9669
US

V. Phone/Fax

Practice location:
  • Phone: 740-928-7686
  • Fax: 740-928-5585
Mailing address:
  • Phone: 740-928-7686
  • Fax: 740-928-5585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number451
License Number StateOH

VIII. Authorized Official

Name: JERRY A MANTONYA
Title or Position: CLINIC OWNER
Credential: D.C.
Phone: 740-928-7686