1134507965 NPI number — DR. CHRISSY M MANNING OD

Table of content: DR. CHRISSY M MANNING OD (NPI 1134507965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134507965 NPI number — DR. CHRISSY M MANNING OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANNING
Provider First Name:
CHRISSY
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134507965
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
239 S WASHINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38701-4234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-332-0163
Provider Business Mailing Address Fax Number:
662-378-3394

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-579-3737
Provider Business Practice Location Address Fax Number:
662-579-3505
Provider Enumeration Date:
05/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  S-D31-TA-A02 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 953 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 190905 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com