Provider Demographics
NPI:1679172944
Name:MANILLA, LEA ROSE (LAC, DIPL OM)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:ROSE
Last Name:MANILLA
Suffix:
Gender:F
Credentials:LAC, DIPL OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 PITTSFORD PALMYRA RD STE 350
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3503
Mailing Address - Country:US
Mailing Address - Phone:585-598-3866
Mailing Address - Fax:
Practice Address - Street 1:6800 PITTSFORD PALMYRA RD STE 350
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3503
Practice Address - Country:US
Practice Address - Phone:585-598-3866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00145900171100000X
NY006834-01171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist