Provider Demographics
NPI:1063194520
Name:ZAVALA, MANUEL MENDEZ
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:MENDEZ
Last Name:ZAVALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5869 RED FOX RUN
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056-5083
Mailing Address - Country:US
Mailing Address - Phone:320-465-1434
Mailing Address - Fax:
Practice Address - Street 1:5869 RED FOX RUN
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MN
Practice Address - Zip Code:55056-5083
Practice Address - Country:US
Practice Address - Phone:320-465-1434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver