Healthcare Provider Details

I. General information

NPI: 1386121580
Provider Name (Legal Business Name): MANA VASCULAR CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 08/11/2024
Certification Date: 08/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18555 N 79TH AVE STE B101
GLENDALE AZ
85308-8372
US

IV. Provider business mailing address

14780 W MOUNTAIN VIEW BLVD STE 120
SURPRISE AZ
85374-7280
US

V. Phone/Fax

Practice location:
  • Phone: 520-979-7095
  • Fax: 623-594-2252
Mailing address:
  • Phone: 520-979-7095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LANNERY SIOELI LAUVAO
Title or Position: OWNER
Credential: MD
Phone: 520-979-7095