Provider Demographics
NPI:1679792477
Name:DONALD P. MAMMANO, D.C., S.C.
Entity type:Organization
Organization Name:DONALD P. MAMMANO, D.C., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:MAMMANO
Authorized Official - Suffix:
Authorized Official - Credentials:DC, FACO
Authorized Official - Phone:815-434-5555
Mailing Address - Street 1:1304 GEMINI CIR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-1689
Mailing Address - Country:US
Mailing Address - Phone:815-434-5555
Mailing Address - Fax:815-434-5568
Practice Address - Street 1:1304 GEMINI CIR
Practice Address - Street 2:SUITE 2
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1689
Practice Address - Country:US
Practice Address - Phone:815-434-5555
Practice Address - Fax:815-434-5568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-003506111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5015067-69OtherBLUE CROSS/BLUE SHIELD
ILT35344Medicare UPIN
IL211850Medicare PIN