Provider Demographics
NPI:1124388210
Name:MANTZ, KURT J
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:J
Last Name:MANTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 S MAIN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3389
Mailing Address - Country:US
Mailing Address - Phone:435-723-1799
Mailing Address - Fax:
Practice Address - Street 1:862 S MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3389
Practice Address - Country:US
Practice Address - Phone:435-723-1799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency