Provider Demographics
NPI:1063509776
Name:MONGIELLO, ROBERT ANDREW (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ANDREW
Last Name:MONGIELLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6008 RINGGOLD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37412-3828
Mailing Address - Country:US
Mailing Address - Phone:423-855-1100
Mailing Address - Fax:
Practice Address - Street 1:6008 RINGGOLD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37412-3828
Practice Address - Country:US
Practice Address - Phone:423-855-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC452111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0050282Medicare UPIN
TN3673551Medicare PIN