Provider Demographics
NPI:1912167057
Name:HEALTHSOURCE OF BANGOR S C
Entity Type:Organization
Organization Name:HEALTHSOURCE OF BANGOR S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MANZELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-486-4899
Mailing Address - Street 1:PO BOX 410
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:WI
Mailing Address - Zip Code:54614-0410
Mailing Address - Country:US
Mailing Address - Phone:608-486-4899
Mailing Address - Fax:608-486-4661
Practice Address - Street 1:1505 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:WI
Practice Address - Zip Code:54614-0410
Practice Address - Country:US
Practice Address - Phone:608-486-4899
Practice Address - Fax:608-486-4661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2555111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty