Provider Demographics
NPI:1144398991
Name:VANTIEM, MARVIN MICHAEL JR (DC)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:MICHAEL
Last Name:VANTIEM
Suffix:JR
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 1:920 W BROADWAY
Mailing Address - Street 2:PO BOX 622
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960
Mailing Address - Country:US
Mailing Address - Phone:574-583-5811
Mailing Address - Fax:574-583-0949
Practice Address - Street 1:920 W BROADWAY
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960
Practice Address - Country:US
Practice Address - Phone:574-583-5811
Practice Address - Fax:574-583-0949
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN586111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000184607OtherBCBS
000000184607OtherBCBS
920680Medicare ID - Type Unspecified