Healthcare Provider Details

I. General information

NPI: 1629556501
Provider Name (Legal Business Name): CARLOS JORDAN MANZANO MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23700 CAMINO DEL SOL
TORRANCE CA
90505-5017
US

IV. Provider business mailing address

PO BOX 4570
PALOS VERDES PENINSULA CA
90274-9607
US

V. Phone/Fax

Practice location:
  • Phone: 310-530-1151
  • Fax: 310-626-9390
Mailing address:
  • Phone: 424-400-7748
  • Fax: 424-400-7749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA106140
License Number StateCA

VIII. Authorized Official

Name: DR. CARLOS JORDAN-MANZANO
Title or Position: OWNER
Credential: MD
Phone: 424-400-7748