Provider Demographics
NPI:1518241074
Name:MIRANDA, JOSE MANUEL (MT)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MANUEL
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15920 S RANCHO SAHUARITA BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SAHUARITA
Mailing Address - State:AZ
Mailing Address - Zip Code:85629-8012
Mailing Address - Country:US
Mailing Address - Phone:520-867-8064
Mailing Address - Fax:520-867-8063
Practice Address - Street 1:15920 S RANCHO SAHUARITA BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:SAHUARITA
Practice Address - State:AZ
Practice Address - Zip Code:85629-8012
Practice Address - Country:US
Practice Address - Phone:520-867-8064
Practice Address - Fax:520-867-8063
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-01325P225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist