Provider Demographics
NPI:1164569562
Name:JERRY A MANTONYA
Entity Type:Organization
Organization Name:JERRY A MANTONYA
Other - Org Name:MANTONYA CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANTONYA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:740-928-7686
Mailing Address - Street 1:149 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:OH
Mailing Address - Zip Code:43025-9669
Mailing Address - Country:US
Mailing Address - Phone:740-928-7686
Mailing Address - Fax:740-928-5585
Practice Address - Street 1:149 N HIGH ST
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:OH
Practice Address - Zip Code:43025-9669
Practice Address - Country:US
Practice Address - Phone:740-928-7686
Practice Address - Fax:740-928-5585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2816813Medicaid
OH000000160597OtherANTHEM BC BS
OH=========01OtherWORKERS COMP
OH2816813Medicaid