Provider Demographics
NPI:1366512444
Name:SHEILA R MANE MD PC
Entity type:Organization
Organization Name:SHEILA R MANE MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIRENDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-654-0889
Mailing Address - Street 1:1730 E BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1730 E BEVERLY AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3500
Practice Address - Country:US
Practice Address - Phone:928-681-3960
Practice Address - Fax:928-869-0067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27651332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ474742Medicaid
0352815OtherOTHER ID NUMBER-COMMERCIAL NUMBER