Healthcare Provider Details

I. General information

NPI: 1861476145
Provider Name (Legal Business Name): ELLIOT CHARLES MANESS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 SILVER CREEK RD STE 111
BULLHEAD CITY AZ
86442-8343
US

IV. Provider business mailing address

2755 SILVER CREEK RD STE 111
BULLHEAD CITY AZ
86442-8343
US

V. Phone/Fax

Practice location:
  • Phone: 928-704-7163
  • Fax: 928-444-1326
Mailing address:
  • Phone: 928-704-7163
  • Fax: 928-444-1326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number3609
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: