Provider Demographics
NPI:1790226736
Name:MANTIK, MIRIAH (LACOM)
Entity Type:Individual
Prefix:
First Name:MIRIAH
Middle Name:
Last Name:MANTIK
Suffix:
Gender:F
Credentials:LACOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20700 CHIPPENDALE AVE W
Mailing Address - Street 2:SUITE 7
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-8207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20700 CHIPPENDALE AVE W
Practice Address - Street 2:SUITE 7
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024-8207
Practice Address - Country:US
Practice Address - Phone:651-460-9449
Practice Address - Fax:612-326-9581
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN1773171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist