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General NPI Number Information
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NPI Number | 1912167057
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Entity Type | Organization
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Legal Business Name | HEALTHSOURCE OF BANGOR S C
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Dates
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Enumeration Date | 06/12/2008
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Last Update Date | 06/12/2008
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Provider Practice Location Address
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Address Line | 1505 COMMERCIAL ST
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City | BANGOR
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State | WI
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Zip | 54614-0410
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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 | PO BOX 410
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City | BANGOR
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State | WI
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Zip | 54614-0410
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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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Authorized Official
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Title or Position | DOCTOR OF CHIROPRACTIC
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Name | DR. JACK ANTHONY MANZELLA
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Credential | DC
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Telephone | 608-486-4899
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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
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License Number State | WI
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