Provider Demographics
NPI:1619369881
Name:MANUEL PHYSICAL THERAPY AND SPORTS PERFORMANCE
Entity Type:Organization
Organization Name:MANUEL PHYSICAL THERAPY AND SPORTS PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PTA
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLANDO
Authorized Official - Middle Name:E
Authorized Official - Last Name:MANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-639-3547
Mailing Address - Street 1:519 SOUTHSHORE LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-4100
Mailing Address - Country:US
Mailing Address - Phone:770-639-3547
Mailing Address - Fax:
Practice Address - Street 1:519 SOUTHSHORE LN
Practice Address - Street 2:STE. 309
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-4100
Practice Address - Country:US
Practice Address - Phone:770-639-3547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-25
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA001792261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy