Provider Demographics
NPI:1891029245
Name:MANDITCH, CHRISTY (LAC)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:
Last Name:MANDITCH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:NAOMI
Other - Middle Name:
Other - Last Name:MANDITCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:PO BOX 1668
Mailing Address - Street 2:
Mailing Address - City:MATTITUCK
Mailing Address - State:NY
Mailing Address - Zip Code:11952-0904
Mailing Address - Country:US
Mailing Address - Phone:631-807-5120
Mailing Address - Fax:
Practice Address - Street 1:22 PARK AVE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:NH
Practice Address - Zip Code:03574
Practice Address - Country:US
Practice Address - Phone:631-807-5120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH153171100000X
NY002944171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist