Healthcare Provider Details

I. General information

NPI: 1043452154
Provider Name (Legal Business Name): BRUCE L MANNING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2009
Last Update Date: 05/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 BRIARTHORN CRESCENT DR
WADSWORTH OH
44281-7501
US

IV. Provider business mailing address

665 BRIARTHORN CRESCENT DR
WADSWORTH OH
44281-7501
US

V. Phone/Fax

Practice location:
  • Phone: 330-336-9177
  • Fax: 330-335-3318
Mailing address:
  • Phone: 330-336-9177
  • Fax: 330-335-3318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3551/T547
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberT547
License Number StateOH

VIII. Authorized Official

Name: BRUCE L MANNING
Title or Position: OWNER
Credential:
Phone: 330-336-9177