Healthcare Provider Details

I. General information

NPI: 1235869934
Provider Name (Legal Business Name): MARK DANIEL MANTHEI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 OHRAZDA LN
EAST WENNATCHEE WA
98802
US

IV. Provider business mailing address

6642 CLAYTON RD # 403
SAINT LOUIS MO
63117-1602
US

V. Phone/Fax

Practice location:
  • Phone: 636-226-4159
  • Fax:
Mailing address:
  • Phone: 636-226-4159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: