Provider Demographics
NPI:1346839768
Name:MANTENO CHIROPRACTIC & WELLNESS CENTER
Entity Type:Organization
Organization Name:MANTENO CHIROPRACTIC & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOTTA
Authorized Official - Suffix:
Authorized Official - Credentials:CHIROPRACTOR
Authorized Official - Phone:815-200-4362
Mailing Address - Street 1:43 W SECOND ST
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-1240
Mailing Address - Country:US
Mailing Address - Phone:815-200-4362
Mailing Address - Fax:
Practice Address - Street 1:43 W SECOND ST
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-1240
Practice Address - Country:US
Practice Address - Phone:815-200-4362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty