Provider Demographics
NPI:1366014979
Name:CARRANZA, MANUEL
Entity Type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:
Last Name:CARRANZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:572 CENTENNIAL WAY
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-2923
Mailing Address - Country:US
Mailing Address - Phone:209-947-4481
Mailing Address - Fax:
Practice Address - Street 1:572 CENTENNIAL WAY
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-2923
Practice Address - Country:US
Practice Address - Phone:209-947-4481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC7195578172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver