Basic Information
Provider Information | |||||||||
NPI: | 1477548915 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANOLIAN | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 40 | ||||||||
Address2: |   | ||||||||
City: | SOUTHBRIDGE | ||||||||
State: | MA | ||||||||
PostalCode: | 015500040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5089097799 | ||||||||
FaxNumber: | 5087642432 | ||||||||
Practice Location | |||||||||
Address1: | 94 SOUTH ST | ||||||||
Address2: |   | ||||||||
City: | SOUTHBRIDGE | ||||||||
State: | MA | ||||||||
PostalCode: | 015504000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5087642772 | ||||||||
FaxNumber: | 5087642833 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2005 | ||||||||
LastUpdateDate: | 12/22/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 1871 | MA | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
No ID Information.