Provider Demographics
NPI:1134456262
Name:MANNENBACH, JAMES ARLEN (DPT)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ARLEN
Last Name:MANNENBACH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2780 E BARNETT RD
Mailing Address - Street 2:STE. 130
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8674
Mailing Address - Country:US
Mailing Address - Phone:541-779-6146
Mailing Address - Fax:541-734-7592
Practice Address - Street 1:2780 E BARNETT RD
Practice Address - Street 2:STE. 130
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8674
Practice Address - Country:US
Practice Address - Phone:541-779-6146
Practice Address - Fax:541-734-7592
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5983225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500626199Medicaid
OR500626199Medicaid