Provider Demographics
NPI:1013383215
Name:MANETTE CLINIC A PROFESSIONAL SERVICE CORPORATION
Entity Type:Organization
Organization Name:MANETTE CLINIC A PROFESSIONAL SERVICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPOON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, ARNP
Authorized Official - Phone:360-621-2696
Mailing Address - Street 1:PO BOX 1266
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337-0507
Mailing Address - Country:US
Mailing Address - Phone:360-621-2696
Mailing Address - Fax:
Practice Address - Street 1:1100 WHEATON WAY
Practice Address - Street 2:SUITE F AND G
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-4459
Practice Address - Country:US
Practice Address - Phone:360-621-2696
Practice Address - Fax:844-602-4646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-11
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007455261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center