Provider Demographics
NPI:1629271663
Name:RODRIGUEZ- MANALO, MIA ANGELICA OCAMPO
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:ANGELICA OCAMPO
Last Name:RODRIGUEZ- MANALO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:A
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:50 RIEDER RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2805
Mailing Address - Country:US
Mailing Address - Phone:732-322-7123
Mailing Address - Fax:
Practice Address - Street 1:50 RIEDER RD
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-2805
Practice Address - Country:US
Practice Address - Phone:732-322-7123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01000600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist