Provider Demographics
NPI:1689297152
Name:MANTOOTH PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:MANTOOTH PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:VIVIAN
Authorized Official - Last Name:MANTOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:270-589-1730
Mailing Address - Street 1:301 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754
Mailing Address - Country:US
Mailing Address - Phone:270-589-1730
Mailing Address - Fax:
Practice Address - Street 1:301 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1256
Practice Address - Country:US
Practice Address - Phone:270-589-1730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty