Provider Demographics
NPI:1538230768
Name:MANRIQUEZ, STEPHANIE LURETHA (LMT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LURETHA
Last Name:MANRIQUEZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 NE GREENWOOD AVE
Mailing Address - Street 2:#203
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4569
Mailing Address - Country:US
Mailing Address - Phone:541-317-9018
Mailing Address - Fax:541-317-9018
Practice Address - Street 1:644 NE GREENWOOD AVE
Practice Address - Street 2:#203
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4569
Practice Address - Country:US
Practice Address - Phone:541-317-9018
Practice Address - Fax:541-317-9018
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7276174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist