=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801695010
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. AUSTIN MENTZEL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2025
-----------------------------------------------------
Last Update Date | 03/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1370 S COMMERCIAL ST
-----------------------------------------------------
City | NEENAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54956-4636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-720-6300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W2050 CAFE CT
-----------------------------------------------------
City | BRILLION
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54110-9137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-450-4239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 6290-12
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------