Provider Demographics
NPI:1689744294
Name:MANALO, JOSEPH BAUTISTA (PT)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:BAUTISTA
Last Name:MANALO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78078 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-8173
Mailing Address - Country:US
Mailing Address - Phone:760-345-9934
Mailing Address - Fax:760-345-3086
Practice Address - Street 1:78078 COUNTRY CLUB DR
Practice Address - Street 2:SUITE 205
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203-8173
Practice Address - Country:US
Practice Address - Phone:760-345-9934
Practice Address - Fax:760-345-3086
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28404225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT28404OtherPT LISENCE NUMBER
CA0PT284040Medicare ID - Type UnspecifiedMEDICARE NUMBER