Provider Demographics
NPI:1093325375
Name:MANZANA FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:MANZANA FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARI CARLO
Authorized Official - Middle Name:BICIERRO
Authorized Official - Last Name:MANZANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-714-1560
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-0066
Mailing Address - Country:US
Mailing Address - Phone:661-714-1560
Mailing Address - Fax:
Practice Address - Street 1:2410 COMMERCE TRL
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-4003
Practice Address - Country:US
Practice Address - Phone:760-332-8688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center