MEDICARE: MR. THEODIS ROOSEVELT MANNING B.S. ENGINEERING

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	175T00000X	Peer Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00000000000000000000	OTHER	OK	N/A

General Provider Information

NPI Number	:	1225316706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THEODIS ROOSEVELT MANNING B.S. ENGINEERING

Provider Business Mailing Address
First Line	:	8306 NE 10TH ST
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-7155
Country	:	US
Telephone Number	:	405-732-0573
Fax Number	:

Provider Business Practice Location Address
First Line	:	8306 NE 10TH ST
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-7155
Country	:	US
Telephone Number	:	405-732-0573
Fax Number	:

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

Provider Enumeration Date	:	08/01/2011
Last Update Date	:	04/05/2024

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