MEDICARE: MARI CARLO MANZANA, M.D., INC.

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	207Q00000X	Family Medicine Physician
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1336752526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARI CARLO MANZANA, M.D., INC.

Provider Business Mailing Address
First Line	:	PO BOX 66
Second Line	:
City	:	IMPERIAL
State	:	CA
Zip	:	92251-0066
Country	:	US
Telephone Number	:	760-332-8688
Fax Number	:	847-221-6838

Provider Business Practice Location Address
First Line	:	2410 COMMERCE TRL
Second Line	:
City	:	IMPERIAL
State	:	CA
Zip	:	92251-4003
Country	:	US
Telephone Number	:	661-714-1560
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MARI CARLO MANZANA
Credential	:	MD
Telephone Number	:	661-714-1560

Provider Enumeration Date	:	08/26/2020
Last Update Date	:	09/05/2020

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