Provider Demographics
NPI:1609831973
Name:MANNEN, DANIEL LEROY (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:LEROY
Last Name:MANNEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1864 COLUMBIA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-1733
Mailing Address - Country:US
Mailing Address - Phone:503-397-2020
Mailing Address - Fax:503-397-7701
Practice Address - Street 1:1864 COLUMBIA BLVD
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-1733
Practice Address - Country:US
Practice Address - Phone:503-397-2020
Practice Address - Fax:503-397-7701
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR 1494 ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR127902Medicaid
OR127902Medicaid
OR0196560002Medicare NSC
ORR103951Medicare PIN