MEDICARE: MR. AYRTON EMERSON MANZANARES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1871238279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. AYRTON EMERSON MANZANARES

Provider Business Mailing Address
First Line	:	21600 OAXNARD STREET, SUITE 1030, WOODLAND HILLS, CA
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	91367
Country	:	US
Telephone Number	:	877-206-1009
Fax Number	:

Provider Business Practice Location Address
First Line	:	21600 OAXNARD STREET, SUITE 1030, WOODLAND HILLS, CA
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	91367
Country	:	US
Telephone Number	:	877-206-1009
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2022
Last Update Date	:	04/29/2022

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