=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831465731
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREGORY C MANOS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2012
-----------------------------------------------------
Last Update Date | 10/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5151 N ORACLE RD STE 129
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85704-3757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-408-4900
-----------------------------------------------------
Fax | 520-408-6903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5151 N ORACLE RD STE 129
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85704-3757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-408-4900
-----------------------------------------------------
Fax | 520-408-6903
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | GREGG MANOS
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 520-408-4900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 8051
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------