1922441336 NPI number — SHAWN MICHELE MANVELL

Table of content: SHAWN MICHELE MANVELL (NPI 1922441336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922441336 NPI number — SHAWN MICHELE MANVELL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANVELL
Provider First Name:
SHAWN
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1922441336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 GRANADA ST
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
CAMARILLO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93010-7866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-383-1501
Provider Business Mailing Address Fax Number:
805-384-0478

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 GRANADA ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
CAMARILLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93010-7866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-383-1501
Provider Business Practice Location Address Fax Number:
805-384-0478
Provider Enumeration Date:
04/16/2013

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: 235Z00000X , with the licence number:  20375 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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