Provider Demographics
NPI:1679620603
Name:MANUEL MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:MANUEL MEDICAL CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:POWLIN
Authorized Official - Middle Name:V
Authorized Official - Last Name:MANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-984-0110
Mailing Address - Street 1:104 GENEVIEVE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-4811
Mailing Address - Country:US
Mailing Address - Phone:337-984-0110
Mailing Address - Fax:337-981-7210
Practice Address - Street 1:104 GENEVIEVE DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-4811
Practice Address - Country:US
Practice Address - Phone:337-984-0110
Practice Address - Fax:337-981-7210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207K00000X, 208000000X
LAAP05389363LP0200X
LAAP07960363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2138332Medicaid
LA1033901Medicaid
LA1171689Medicaid
LA2381369Medicaid