Provider Demographics
NPI:1255534574
Name:MANU, KWAKU BOAFO
Entity type:Individual
Prefix:MR
First Name:KWAKU
Middle Name:BOAFO
Last Name:MANU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11863 BENHAM RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63138-1308
Mailing Address - Country:US
Mailing Address - Phone:413-438-0033
Mailing Address - Fax:
Practice Address - Street 1:11863 BENHAM RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63138-1308
Practice Address - Country:US
Practice Address - Phone:413-438-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO4947120001171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4947120001Medicare ID - Type UnspecifiedOXFORD MEDICAL SUPPLIES