Provider Demographics
NPI:1457531808
Name:CHARLES D. MANTER DO PC
Entity Type:Organization
Organization Name:CHARLES D. MANTER DO PC
Other - Org Name:FAMILY MEDICAL PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MANTER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-352-3274
Mailing Address - Street 1:2918 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-5457
Mailing Address - Country:US
Mailing Address - Phone:970-352-3274
Mailing Address - Fax:970-352-3279
Practice Address - Street 1:2918 W 10TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-5457
Practice Address - Country:US
Practice Address - Phone:970-352-3274
Practice Address - Fax:970-352-3279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO00522830Medicaid
CO00522830Medicaid
COC462068Medicare PIN