1457579864 NPI number — DEBRA WATERHOUSE MANCA RD

Table of content: DEBRA WATERHOUSE MANCA RD (NPI 1457579864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457579864 NPI number — DEBRA WATERHOUSE MANCA RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANCA
Provider First Name:
DEBRA
Provider Middle Name:
WATERHOUSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WATERHOUSE
Provider Other First Name:
DEBRA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457579864
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 WHITE COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-339-3848
Provider Business Mailing Address Fax Number:
510-339-3858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 ORINDA WAY
Provider Second Line Business Practice Location Address:
SUITE 308
Provider Business Practice Location Address City Name:
ORINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-339-3848
Provider Business Practice Location Address Fax Number:
510-339-3858
Provider Enumeration Date:
04/23/2007

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: 133V00000X , with the licence number:  689963 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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