Healthcare Provider Details

I. General information

NPI: 1811607633
Provider Name (Legal Business Name): MANUEL ALFONSO DAZA MHA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 THURBERS AVE STE 212
PROVIDENCE RI
02905-4721
US

IV. Provider business mailing address

1 MANSFIELD AVE APT B101
MANSFIELD MA
02048-1995
US

V. Phone/Fax

Practice location:
  • Phone: 401-383-5051
  • Fax: 401-432-7082
Mailing address:
  • Phone: 520-612-9551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: