Provider Demographics
NPI:1548457526
Name:MENTO, RICHARD STAVROS (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:STAVROS
Last Name:MENTO
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 1:1770 44TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-3916
Mailing Address - Country:US
Mailing Address - Phone:309-786-7171
Mailing Address - Fax:
Practice Address - Street 1:1770 44TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-3916
Practice Address - Country:US
Practice Address - Phone:309-786-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA5287111N00000X
PADC004823L111N00000X
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0930446Medicaid
IL8182044OtherBCBS OF ILLINOIS
IL8126564OtherBCBS OF ILLINOIS
IL738222Medicare UPIN
IL8126564OtherBCBS OF ILLINOIS