Provider Demographics
NPI:1518262609
Name:VIDAL, MANUEL
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:VIDAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:564 W 160TH ST APT 55
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-6749
Mailing Address - Country:US
Mailing Address - Phone:646-505-8798
Mailing Address - Fax:
Practice Address - Street 1:1018 CASTLE HILL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-6304
Practice Address - Country:US
Practice Address - Phone:718-904-8656
Practice Address - Fax:718-904-8663
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024615225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist