Provider Demographics
NPI:1417142431
Name:MANAHAN, RAYMOND PAMPOLINA (IDC)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:PAMPOLINA
Last Name:MANAHAN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 LA MIRADA
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-4130
Mailing Address - Country:US
Mailing Address - Phone:361-776-4569
Mailing Address - Fax:
Practice Address - Street 1:905 LA MIRADA
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374-4130
Practice Address - Country:US
Practice Address - Phone:361-776-4569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians