MEDICARE: THEODIS MANNING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	392068921	OTHER	OK	PRIVATE AGENCY

General Provider Information

NPI Number	:	1194071357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEODIS MANNING

Provider Business Mailing Address
First Line	:	8320 NE 10TH ST
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-7155
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8320 NE 10TH ST
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-7155
Country	:	US
Telephone Number	:	405-761-3041
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2012
Last Update Date	:	07/25/2012

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Directions to “ THEODIS MANNING ” Practice Location

Language	Start Address	Practice Location

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