Provider Demographics
NPI:1366475212
Name:MANTEUFFEL, MARK (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MANTEUFFEL
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 1:26672 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1222
Mailing Address - Country:US
Mailing Address - Phone:586-756-7670
Mailing Address - Fax:586-756-8279
Practice Address - Street 1:26672 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1222
Practice Address - Country:US
Practice Address - Phone:586-756-7670
Practice Address - Fax:586-756-8279
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301002969111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2099272Medicaid
MI0E06342Medicare ID - Type Unspecified
MIT33150Medicare UPIN