Provider Demographics
NPI:1316331101
Name:MANTRUST, LLC
Entity type:Organization
Organization Name:MANTRUST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-712-1170
Mailing Address - Street 1:2812 HARTFORD HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-4927
Mailing Address - Country:US
Mailing Address - Phone:334-712-1170
Mailing Address - Fax:
Practice Address - Street 1:2812 HARTFORD HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-4927
Practice Address - Country:US
Practice Address - Phone:334-712-1170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty