Provider Demographics
NPI:1003877457
Name:MENTELE, WESLEY A (MPT)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:A
Last Name:MENTELE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:HOWARD
Mailing Address - State:SD
Mailing Address - Zip Code:57349-0039
Mailing Address - Country:US
Mailing Address - Phone:605-772-2131
Mailing Address - Fax:605-772-2041
Practice Address - Street 1:131 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:HOWARD
Practice Address - State:SD
Practice Address - Zip Code:57349
Practice Address - Country:US
Practice Address - Phone:605-772-2131
Practice Address - Fax:605-772-2041
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1326225100000X
SD1337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54130Medicaid
SD5835460Medicaid
SD101119Medicare PIN
ND54130Medicaid
ND24300Medicare PIN