Provider Demographics
NPI:1558486175
Name:MANNINO, MATTHEW J (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:MANNINO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2373 E BASELINE RD
Mailing Address - Street 2:STE100
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2477
Mailing Address - Country:US
Mailing Address - Phone:480-497-2642
Mailing Address - Fax:480-497-1863
Practice Address - Street 1:1549 N BURK ST
Practice Address - Street 2:STE100
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2483
Practice Address - Country:US
Practice Address - Phone:480-497-2642
Practice Address - Fax:480-497-1863
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ4490111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ120514Medicare PIN