Provider Demographics
NPI:1659540961
Name:COLETTE MANNING OD PC
Entity Type:Organization
Organization Name:COLETTE MANNING OD PC
Other - Org Name:WEDGWOOD OPTOMETRY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:COLETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:817-294-7456
Mailing Address - Street 1:6404 MCCART AVE
Mailing Address - Street 2:
Mailing Address - City:FT. WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-4701
Mailing Address - Country:US
Mailing Address - Phone:817-294-7456
Mailing Address - Fax:817-294-5443
Practice Address - Street 1:6404 MCCART AVE
Practice Address - Street 2:
Practice Address - City:FT. WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-4701
Practice Address - Country:US
Practice Address - Phone:817-294-7456
Practice Address - Fax:817-294-5443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2011-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4511T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Y489Medicare PIN