1184774440 NPI number — RAYMOND G. MANS, OD PC

Table of content: (NPI 1184774440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184774440 NPI number — RAYMOND G. MANS, OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAYMOND G. MANS, OD PC
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:
6
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:
1184774440
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 277
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97439-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-997-3331
Provider Business Mailing Address Fax Number:
541-997-9439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
535 9TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-997-3331
Provider Business Practice Location Address Fax Number:
541-997-9439
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANS
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
GENE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
541-997-3331

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1206ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: R00WCYBXB . This is a "MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: R0000WCYBX . This is a "MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: R00WCYBXA . This is a "MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 139325 . This is a "PTAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 410027916 . This is a "PALMETTO GBA" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: R00WCYBXC . This is a "MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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