Provider Demographics
NPI:1659985620
Name:MANZANO, JUAN (LMT)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:MANZANO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 N COURSE DR APT 302
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-3313
Mailing Address - Country:US
Mailing Address - Phone:954-599-1334
Mailing Address - Fax:
Practice Address - Street 1:3090 N COURSE DR APT 302
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-3313
Practice Address - Country:US
Practice Address - Phone:954-599-1334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA44082225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty