Healthcare Provider Details

I. General information

NPI: 1437476140
Provider Name (Legal Business Name): MARCELLA T MANIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 JOHNSON AVE
SLO CA
93401
US

IV. Provider business mailing address

1220 BENNETT WAY SPC 97
TEMPLETON CA
93465-3623
US

V. Phone/Fax

Practice location:
  • Phone: 805-781-4700
  • Fax:
Mailing address:
  • Phone: 805-286-4108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberPT26027
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: