Provider Demographics
NPI:1720298227
Name:MANBECK, TRACEY LYNN
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:MANBECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6905 MARGARUM BND
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-7049
Mailing Address - Country:US
Mailing Address - Phone:614-939-0990
Mailing Address - Fax:
Practice Address - Street 1:1599 W LANE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3924
Practice Address - Country:US
Practice Address - Phone:614-486-9354
Practice Address - Fax:614-486-8036
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5595 T2509152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL574560Medicare ID - Type Unspecified
IL71277Medicare UPIN