Provider Demographics
NPI:1093464158
Name:MANA PERFORMANCE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MANA PERFORMANCE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MANALASTAS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, SCS, COMT, CSCS
Authorized Official - Phone:443-540-8419
Mailing Address - Street 1:80 LYNDON RD
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-9746
Mailing Address - Country:US
Mailing Address - Phone:585-364-1586
Mailing Address - Fax:585-310-0143
Practice Address - Street 1:80 LYNDON RD
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-9746
Practice Address - Country:US
Practice Address - Phone:585-364-1586
Practice Address - Fax:585-310-0143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-23
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty