Provider Demographics
NPI:1407300874
Name:MANETTI, NIKO (DPT)
Entity Type:Individual
Prefix:
First Name:NIKO
Middle Name:
Last Name:MANETTI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 MCALPINE ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:AVOCA
Mailing Address - State:PA
Mailing Address - Zip Code:18641-1104
Mailing Address - Country:US
Mailing Address - Phone:570-842-9323
Mailing Address - Fax:570-842-9362
Practice Address - Street 1:82 N MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-1914
Practice Address - Country:US
Practice Address - Phone:570-282-0200
Practice Address - Fax:570-282-2229
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT025475225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist