| Country Doctor Inc | |
|
13260 N 94th Dr Ste 102 Peoria AZ 85381-4242 | |
| (623) 815-0827 | |
| (623) 875-0325 |
| Full Name | Country Doctor Inc |
|---|---|
| Speciality | Clinic/Center |
| Location | 13260 N 94th Dr Ste 102, Peoria, Arizona |
| Authorized Official Name and Position | Paul Lee Manganelli (PRESIDENT) |
| Authorized Official Contact | 6238150827 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Country Doctor Inc 13260 N 94th Dr Ste 102 Peoria AZ 85381-4242 Ph: (623) 815-0827 | Country Doctor Inc 13260 N 94th Dr Ste 102 Peoria AZ 85381-4242 Ph: (623) 815-0827 |
| NPI Number | 1821550310 |
|---|---|
| Provider Enumeration Date | 04/03/2019 |
| Last Update Date | 04/11/2019 |
| Medicare PECOS PAC ID | 0941533251 |
|---|---|
| Medicare Enrollment ID | O20190531000241 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1821550310 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
| Provider Name | Tammy Manganelli |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1912144866 PECOS PAC ID: 4082760962 Enrollment ID: I20090917000321 |
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