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General NPI Number Information
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NPI Number | 1174652291
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Entity Type | Individual
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Provider Name | JACK ANTHONY MANZELLA D.C.
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Gender | Male
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1505 COMMERCIAL ST. BANGOR FAMILY CHIROPRACTIC
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City | BANGOR
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State | WI
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Zip | 54614
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Country | US
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Telephone | 608-486-4899
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Fax | 608-486-4661
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Provider Business Mailing Address
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Address Line | 22993 CTY. RD. Y JACK A. MANZELLA, D.C.
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City | ROCKLAND
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State | WI
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Zip | 54653
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Country | US
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Telephone | 608-486-4445
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2555-012
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License Number State | WI
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