Healthcare Provider Details

I. General information

NPI: 1992953343
Provider Name (Legal Business Name): MR. VICTOR VERON MANNING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9414 ASHMONT ST
SHREVEPORT LA
71129-4830
US

IV. Provider business mailing address

9414 ASHMONT ST
SHREVEPORT LA
71129-4830
US

V. Phone/Fax

Practice location:
  • Phone: 318-683-0119
  • Fax:
Mailing address:
  • Phone: 318-683-0119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN121799
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: