1679620603 NPI number — MANUEL MEDICAL CLINIC, INC.

Table of content: (NPI 1679620603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679620603 NPI number — MANUEL MEDICAL CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANUEL MEDICAL CLINIC, 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:
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:
1679620603
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 GENEVIEVE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70503-4811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-984-0110
Provider Business Mailing Address Fax Number:
337-981-7210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 GENEVIEVE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70503-4811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-984-0110
Provider Business Practice Location Address Fax Number:
337-981-7210
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANUEL
Authorized Official First Name:
POWLIN
Authorized Official Middle Name:
V
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
337-984-0110

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0200X , with the licence number: AP05389 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: AP07960 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2138332 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1033901 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1171689 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2381369 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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