Provider Demographics
NPI:1689883175
Name:MENTZER, RICKY LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:RICKY
Middle Name:LEE
Last Name:MENTZER
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 1:2866 TAMIAMI TRL
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5126
Mailing Address - Country:US
Mailing Address - Phone:941-627-5414
Mailing Address - Fax:
Practice Address - Street 1:2866 TAMIAMI TRL
Practice Address - Street 2:SUITE C
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5126
Practice Address - Country:US
Practice Address - Phone:941-627-5414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH4981111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH4981OtherLICENSE #
FL70994Medicare ID - Type Unspecified
FLT55089Medicare UPIN