1174997043 NPI number — MANAMED, INC

Table of content: MARYANN ALYCE FORSELL DMD (NPI 1972095339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174997043 NPI number — MANAMED, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANAMED, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1174997043
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1511 W ALTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92704-7219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-922-9278
Provider Business Mailing Address Fax Number:
949-209-4817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1511 W ALTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92704-7219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-922-9278
Provider Business Practice Location Address Fax Number:
949-209-4817
Provider Enumeration Date:
11/16/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HORTON
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
GARY
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
888-508-0712

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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