Provider Demographics
NPI:1881704096
Name:MANZANO MEDICAL GROUP, P.C.
Entity type:Organization
Organization Name:MANZANO MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:SLOAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-727-4919
Mailing Address - Street 1:PO BOX 25701
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-0701
Mailing Address - Country:US
Mailing Address - Phone:505-727-4919
Mailing Address - Fax:505-727-4915
Practice Address - Street 1:505 ELM ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2500
Practice Address - Country:US
Practice Address - Phone:505-727-4919
Practice Address - Fax:505-727-4915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA5074Medicaid