Provider Demographics
NPI:1437382728
Name:MANNERS, BLANCHE BELLE (CCMA)
Entity Type:Individual
Prefix:
First Name:BLANCHE
Middle Name:BELLE
Last Name:MANNERS
Suffix:
Gender:F
Credentials:CCMA
Other - Prefix:
Other - First Name:BLANCHE
Other - Middle Name:BELLE
Other - Last Name:MANNERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CCMA
Mailing Address - Street 1:13560 COUNTY ROUTE 68
Mailing Address - Street 2:
Mailing Address - City:RODMAN
Mailing Address - State:NY
Mailing Address - Zip Code:13682-2159
Mailing Address - Country:US
Mailing Address - Phone:315-232-4059
Mailing Address - Fax:
Practice Address - Street 1:18945 FM 2252 STE 115
Practice Address - Street 2:
Practice Address - City:GARDEN RIDGE
Practice Address - State:TX
Practice Address - Zip Code:78266-2797
Practice Address - Country:US
Practice Address - Phone:210-651-0029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12225011261QM1102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1102XAmbulatory Health Care FacilitiesClinic/CenterMilitary Outpatient Operational (Transportable) Component
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY340097481192EMedicare Oscar/Certification
NY12225011Medicare Oscar/Certification