Provider Demographics
NPI:1689496085
Name:MANIDVIPA HEALTH LLC
Entity type:Organization
Organization Name:MANIDVIPA HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:HARIRAJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-268-4100
Mailing Address - Street 1:5 VALLEY BROOK CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:158-01 CROSS BAY BLVD
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414
Practice Address - Country:US
Practice Address - Phone:516-260-6425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care