Healthcare Provider Details

I. General information

NPI: 1235609934
Provider Name (Legal Business Name): MARIO GAVAN MANACCI RN, BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

17819 AUBURN RD
CHAGRIN FALLS OH
44023-6130
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-2200
  • Fax:
Mailing address:
  • Phone: 440-708-4721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.428670
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.024360
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: