Provider Demographics
NPI:1356984041
Name:MCKENZIE, MANUEL CARL III
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:CARL
Last Name:MCKENZIE
Suffix:III
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 1:4893 CANDLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-1605
Mailing Address - Country:US
Mailing Address - Phone:770-896-1977
Mailing Address - Fax:
Practice Address - Street 1:4893 CANDLEWOOD LN
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-1605
Practice Address - Country:US
Practice Address - Phone:770-896-1977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home