Provider Demographics
NPI:1134952617
Name:CISNEROS, MANUEL ANTONIO SR (OWNER)
Entity type:Individual
Prefix:MRS
First Name:MANUEL
Middle Name:ANTONIO
Last Name:CISNEROS
Suffix:SR
Gender:M
Credentials:OWNER
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2260 PALM BEACH LAKES BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-3411
Mailing Address - Country:US
Mailing Address - Phone:561-376-9305
Mailing Address - Fax:561-576-9307
Practice Address - Street 1:2260 PALM BEACH LAKES BLVD STE 212
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-3411
Practice Address - Country:US
Practice Address - Phone:561-376-9305
Practice Address - Fax:561-576-9307
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2999961793747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider