Provider Demographics
NPI:1649485707
Name:MAMMEN CHIROPRACTIC, PSC
Entity type:Organization
Organization Name:MAMMEN CHIROPRACTIC, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:P
Authorized Official - Last Name:MAMMEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-689-3335
Mailing Address - Street 1:6917 SANDSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219
Mailing Address - Country:US
Mailing Address - Phone:502-689-3335
Mailing Address - Fax:
Practice Address - Street 1:6917 SANDSTONE BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219
Practice Address - Country:US
Practice Address - Phone:502-689-3335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4665111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85002608Medicaid
KY85002608Medicaid
KYU92737Medicare UPIN
7389Medicare PIN