Healthcare Provider Details

I. General information

NPI: 1154837722
Provider Name (Legal Business Name): CHERYL MANIAK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11115 W. HWY. 24 UNIT 2C
DIVIDE CO
80814-8081
US

IV. Provider business mailing address

PO BOX 928
DIVIDE CO
80814-0928
US

V. Phone/Fax

Practice location:
  • Phone: 719-687-6416
  • Fax: 719-687-6416
Mailing address:
  • Phone: 719-687-6416
  • Fax: 719-687-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number168066
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: