Healthcare Provider Details

I. General information

NPI: 1518965318
Provider Name (Legal Business Name): JERRY ALLEN MANTONYA D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 N 21ST ST
NEWARK OH
43055-2919
US

IV. Provider business mailing address

919 N 21ST ST
NEWARK OH
43055-2919
US

V. Phone/Fax

Practice location:
  • Phone: 740-366-6601
  • Fax: 740-366-6286
Mailing address:
  • Phone: 740-366-6601
  • Fax: 740-366-6286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: