Provider Demographics
NPI:1578074225
Name:BOTROS, MINA (DC)
Entity Type:Individual
Prefix:DR
First Name:MINA
Middle Name:
Last Name:BOTROS
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 1:5306 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4913
Mailing Address - Country:US
Mailing Address - Phone:414-332-0859
Mailing Address - Fax:
Practice Address - Street 1:5306 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4913
Practice Address - Country:US
Practice Address - Phone:414-332-0859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-21
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5295-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor