Provider Demographics
NPI:1891983029
Name:MANKTELOW, RUSSELL WORTH (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:WORTH
Last Name:MANKTELOW
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 1:1111 N GILBERT RD
Mailing Address - Street 2:115
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2313
Mailing Address - Country:US
Mailing Address - Phone:480-892-5631
Mailing Address - Fax:480-892-5649
Practice Address - Street 1:1111 N GILBERT RD
Practice Address - Street 2:115
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2313
Practice Address - Country:US
Practice Address - Phone:480-892-5631
Practice Address - Fax:480-892-5649
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7839111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor