Provider Demographics
NPI:1780560714
Name:MANIS, SAMUEL W (CHW)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:W
Last Name:MANIS
Suffix:
Gender:M
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14229 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JAMUL
Mailing Address - State:CA
Mailing Address - Zip Code:91935-3239
Mailing Address - Country:US
Mailing Address - Phone:619-733-3698
Mailing Address - Fax:
Practice Address - Street 1:14229 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:JAMUL
Practice Address - State:CA
Practice Address - Zip Code:91935-3239
Practice Address - Country:US
Practice Address - Phone:619-733-3698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker