Provider Demographics
NPI:1437605110
Name:MANIBERRY HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:MANIBERRY HEALTHCARE SERVICES
Other - Org Name:MANIBERRY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:NWASOKA
Authorized Official - Last Name:ADESOKAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, FNP-C
Authorized Official - Phone:559-708-7181
Mailing Address - Street 1:1114 OLIVEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-1210
Mailing Address - Country:US
Mailing Address - Phone:209-349-1896
Mailing Address - Fax:
Practice Address - Street 1:1114 OLIVEWOOD DR
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-1210
Practice Address - Country:US
Practice Address - Phone:209-349-1896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003522261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1114392990Medicare NSC