Healthcare Provider Details

I. General information

NPI: 1962659474
Provider Name (Legal Business Name): CECILE MARIE MCMANUS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10920 SMOKEY MOUNTAIN TRL
BLUE MOUNDS WI
53517-9668
US

IV. Provider business mailing address

10920 SMOKEY MOUNTAIN TRL
BLUE MOUNDS WI
53517-9668
US

V. Phone/Fax

Practice location:
  • Phone: 608-437-6278
  • Fax: 608-437-6279
Mailing address:
  • Phone: 608-437-6278
  • Fax: 608-437-6279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2036-029 (CD)
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: