Provider Demographics
NPI:1508063371
Name:MANTE PEDIATRICS LLC
Entity Type:Organization
Organization Name:MANTE PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EBENEZER
Authorized Official - Middle Name:
Authorized Official - Last Name:MANTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-313-3846
Mailing Address - Street 1:834 W MEETING ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-6220
Mailing Address - Country:US
Mailing Address - Phone:803-313-3846
Mailing Address - Fax:803-313-3847
Practice Address - Street 1:834 W MEETING ST
Practice Address - Street 2:SUITE C
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-6220
Practice Address - Country:US
Practice Address - Phone:803-313-3846
Practice Address - Fax:803-313-3847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4702Medicaid
SCGP4702Medicaid