Provider Demographics
NPI:1104439777
Name:MIDWEST ALTERNATIVE TREATMENT CLINIC, PC
Entity type:Organization
Organization Name:MIDWEST ALTERNATIVE TREATMENT CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-334-8075
Mailing Address - Street 1:1100 LAKE ST STE 260
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1095
Mailing Address - Country:US
Mailing Address - Phone:708-334-8075
Mailing Address - Fax:
Practice Address - Street 1:1100 LAKE ST STE 260
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1095
Practice Address - Country:US
Practice Address - Phone:708-334-8075
Practice Address - Fax:708-419-2176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy