Provider Demographics
NPI:1366672685
Name:MANALASTAS, RUSSELL JOHN (DPT, CSCS)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:JOHN
Last Name:MANALASTAS
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-1244
Mailing Address - Country:US
Mailing Address - Phone:585-349-2860
Mailing Address - Fax:585-349-2995
Practice Address - Street 1:37 N UNION ST
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-1244
Practice Address - Country:US
Practice Address - Phone:585-349-2860
Practice Address - Fax:585-349-2995
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031540-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist