Provider Demographics
NPI:1447378120
Name:MABANTA, RICHARD A (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:MABANTA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-6966
Mailing Address - Country:US
Mailing Address - Phone:631-427-5777
Mailing Address - Fax:631-427-5888
Practice Address - Street 1:70 MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-6966
Practice Address - Country:US
Practice Address - Phone:631-427-5777
Practice Address - Fax:631-427-5888
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005115111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX62041Medicare ID - Type UnspecifiedCHIROPRACTIC