Provider Demographics
NPI:1790107365
Name:MANTEY, DEREK (MS, ATC, PTA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MANTEY
Suffix:
Gender:M
Credentials:MS, ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31461 RANCHO VIEJO RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-1864
Mailing Address - Country:US
Mailing Address - Phone:949-542-5000
Mailing Address - Fax:949-419-2650
Practice Address - Street 1:31461 RANCHO VIEJO RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1864
Practice Address - Country:US
Practice Address - Phone:949-542-5000
Practice Address - Fax:949-419-2650
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10299225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant