Provider Demographics
NPI:1013697002
Name:MANOLLY, MENA S SR (CPO)
Entity Type:Individual
Prefix:MR
First Name:MENA
Middle Name:S
Last Name:MANOLLY
Suffix:SR
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8845 BARTON ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-3243
Mailing Address - Country:US
Mailing Address - Phone:951-966-7661
Mailing Address - Fax:
Practice Address - Street 1:8845 BARTON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-3243
Practice Address - Country:US
Practice Address - Phone:951-966-7661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224P00000X
CACPO03356224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist