Healthcare Provider Details

I. General information

NPI: 1629861919
Provider Name (Legal Business Name): MIRNA J MANZANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2025
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 BROAD ST
CENTRAL FALLS RI
02863-2835
US

IV. Provider business mailing address

626 BROAD ST
CENTRAL FALLS RI
02863-2835
US

V. Phone/Fax

Practice location:
  • Phone: 401-728-5920
  • Fax:
Mailing address:
  • Phone: 401-728-5920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number201806
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: