Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0401X | Family Doctor - Addiction Medicine | A37515 | CA |
NPI | 1336362599 |
---|---|
Provider Name | Mr. Mario Manese II |
First Address | Highland, CA 92346-5308 |
Second Address | Palm Springs, CA 92262-4880 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2007 |
Last Update Date | 08/07/2007 |