Provider Demographics
NPI:1174652291
Name:MANZELLA, JACK ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ANTHONY
Last Name:MANZELLA
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 1:22993 CTY. RD. Y
Mailing Address - Street 2:JACK A. MANZELLA, D.C.
Mailing Address - City:ROCKLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54653
Mailing Address - Country:US
Mailing Address - Phone:608-486-4445
Mailing Address - Fax:
Practice Address - Street 1:1505 COMMERCIAL ST.
Practice Address - Street 2:BANGOR FAMILY CHIROPRACTIC
Practice Address - City:BANGOR
Practice Address - State:WI
Practice Address - Zip Code:54614
Practice Address - Country:US
Practice Address - Phone:608-486-4899
Practice Address - Fax:608-486-4661
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2555-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35337Medicare ID - Type Unspecified