Provider Demographics
NPI:1639569841
Name:DE ALBA, MANUEL (MAT, ATC, CES)
Entity Type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:
Last Name:DE ALBA
Suffix:
Gender:M
Credentials:MAT, ATC, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 21ST ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1123 COLEMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-1104
Practice Address - Country:US
Practice Address - Phone:408-556-7761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-26
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT57372255A2300X
20000099682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer