Provider Demographics
NPI:1336324185
Name:MANELL & COOPER OPTOMETRIST
Entity Type:Organization
Organization Name:MANELL & COOPER OPTOMETRIST
Other - Org Name:MANELL & COOPER OPTOMETRIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-745-5412
Mailing Address - Street 1:251 E 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4901
Mailing Address - Country:US
Mailing Address - Phone:760-745-5412
Mailing Address - Fax:760-745-2752
Practice Address - Street 1:251 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4901
Practice Address - Country:US
Practice Address - Phone:760-745-5412
Practice Address - Fax:760-745-2752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10476152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGDS001100Medicaid
CAGDS001100Medicaid
CAWY2485Medicare PIN