Provider Demographics
NPI:1649388380
Name:MANCINI, MICHAEL L (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:MANCINI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 BARRIE RD
Mailing Address - Street 2:#610
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:775 PRAIRIE CENTER DR
Practice Address - Street 2:#250
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7314
Practice Address - Country:US
Practice Address - Phone:952-944-5314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4345111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor