1346374758 NPI number — DR. STEPHANIE MANCUSO RD, DC, FICPA

Table of content: DR. STEPHANIE MANCUSO RD, DC, FICPA (NPI 1346374758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346374758 NPI number — DR. STEPHANIE MANCUSO RD, DC, FICPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANCUSO
Provider First Name:
STEPHANIE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
RD, DC, FICPA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MANCUSO-RENNIE
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD, DC, FICPA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346374758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8402 E SHEA BLVD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85260-6635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-219-4439
Provider Business Mailing Address Fax Number:
480-219-4569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8402 E SHEA BLVD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85260-6635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-219-4439
Provider Business Practice Location Address Fax Number:
480-219-4569
Provider Enumeration Date:
03/15/2007

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: 111NN1001X , with the licence number:  5988 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AZ0941110 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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