MEDICARE: MANTALITY IOWA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1942717681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANTALITY IOWA LLC

Provider Business Mailing Address
First Line	:	595 ASHLEY CT STE 5
Second Line	:
City	:	NORTH LIBERTY
State	:	IA
Zip	:	52317-4758
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	595 ASHLEY CT STE 5
Second Line	:
City	:	NORTH LIBERTY
State	:	IA
Zip	:	52317-4758
Country	:	US
Telephone Number	:	314-254-2420
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KEVIN J MEURET
Credential	:
Telephone Number	:	314-254-2420

Provider Enumeration Date	:	01/03/2018
Last Update Date	:	01/03/2018

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