Provider Demographics
NPI:1255819066
Name:MANZO, ELIJAH (BA)
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:MANZO
Suffix:
Gender:M
Credentials:BA
Other - Prefix:MR
Other - First Name:ELIJAH
Other - Middle Name:E
Other - Last Name:MANZO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA
Mailing Address - Street 1:3955 SKOFSTAD ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3051
Mailing Address - Country:US
Mailing Address - Phone:714-651-6469
Mailing Address - Fax:
Practice Address - Street 1:1360 S ANAHEIM BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6205
Practice Address - Country:US
Practice Address - Phone:714-225-0169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1396870549Medicaid