Provider Demographics
NPI:1679338347
Name:MANTARAS, CARLOS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:MANTARAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7825 NW 107TH AVE APT 509
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4437
Mailing Address - Country:US
Mailing Address - Phone:787-617-1769
Mailing Address - Fax:
Practice Address - Street 1:12093 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-1607
Practice Address - Country:US
Practice Address - Phone:786-646-0098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH14325111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor