Provider Demographics
NPI:1962677807
Name:MANDA, ARISTOTLE K (PT)
Entity Type:Individual
Prefix:MR
First Name:ARISTOTLE
Middle Name:K
Last Name:MANDA
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 1:1201 HEWITT DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-8833
Mailing Address - Country:US
Mailing Address - Phone:254-776-7864
Mailing Address - Fax:
Practice Address - Street 1:1201 HEWITT DR
Practice Address - Street 2:SUITE 202
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8833
Practice Address - Country:US
Practice Address - Phone:254-776-7864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1201000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
080080257OtherCOLORADO DRIVERS LICENSE