Provider Demographics
NPI:1417020637
Name:MANRIQUE, JULIAN MARTIN (MPT, OCS)
Entity Type:Individual
Prefix:
First Name:JULIAN
Middle Name:MARTIN
Last Name:MANRIQUE
Suffix:
Gender:M
Credentials:MPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30212 TOMAS
Mailing Address - Street 2:SUITE 120
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-2172
Mailing Address - Country:US
Mailing Address - Phone:949-709-8770
Mailing Address - Fax:949-709-4064
Practice Address - Street 1:30212 TOMAS
Practice Address - Street 2:SUITE 120
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2172
Practice Address - Country:US
Practice Address - Phone:949-709-8770
Practice Address - Fax:949-709-4064
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24615225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist