Healthcare Provider Details

I. General information

NPI: 1104621754
Provider Name (Legal Business Name): MR. ROBERT MANUS II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date: 05/05/2025
Reactivation Date: 05/27/2025

III. Provider practice location address

1207 E FRUIT ST
SANTA ANA CA
92701-4296
US

IV. Provider business mailing address

1114 S OAK ST
SANTA ANA CA
92701-6062
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-9373
  • Fax:
Mailing address:
  • Phone: 657-636-2142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1593970125
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: