Provider Demographics
NPI:1508031360
Name:MANTIONE, JACK M III (DPT, CSCS)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:M
Last Name:MANTIONE
Suffix:III
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
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Mailing Address - Street 1:112 E 61ST ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-8514
Mailing Address - Country:US
Mailing Address - Phone:212-867-1777
Mailing Address - Fax:212-371-2079
Practice Address - Street 1:112 E 61ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-8514
Practice Address - Country:US
Practice Address - Phone:212-867-1777
Practice Address - Fax:212-371-2079
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2009-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023347-12251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic