Basic Information
| Provider Information | |||||||||
| NPI: | 1629556501 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARLOS JORDAN MANZANO MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4570 | ||||||||
| Address2: | |||||||||
| City: | PALOS VERDES PENINSULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902749607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4244007748 | ||||||||
| FaxNumber: | 4244007749 | ||||||||
| Practice Location | |||||||||
| Address1: | 23700 CAMINO DEL SOL | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905055017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105301151 | ||||||||
| FaxNumber: | 3106269390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2018 | ||||||||
| LastUpdateDate: | 08/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | JORDAN-MANZANO | ||||||||
| AuthorizedOfficialFirstName: | CARLOS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4244007748 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A106140 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.