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General NPI Number Information
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NPI Number | 1386121580
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Entity Type | Organization
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Legal Business Name | MANA VASCULAR CLINIC, PLLC
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Dates
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Enumeration Date | 07/20/2018
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Last Update Date | 08/11/2024
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Provider Practice Location Address
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Address Line | 18555 N 79TH AVE STE B101
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City | GLENDALE
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State | AZ
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Zip | 85308-8372
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Country | US
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Telephone | 520-979-7095
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Fax | 623-594-2252
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Provider Business Mailing Address
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Address Line | 14780 W MOUNTAIN VIEW BLVD STE 120
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City | SURPRISE
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State | AZ
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Zip | 85374-7280
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Country | US
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Telephone | 520-979-7095
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LANNERY SIOELI LAUVAO
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Credential | MD
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Telephone | 520-979-7095
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number |
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License Number State |
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