Provider Demographics
NPI:1255945796
Name:MANEVICH, ROMAN
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:MANEVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 PALM BAY CIR APT A
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-9083
Mailing Address - Country:US
Mailing Address - Phone:832-353-5368
Mailing Address - Fax:
Practice Address - Street 1:4240 PALM BAY CIR APT A
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-9083
Practice Address - Country:US
Practice Address - Phone:832-353-5368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA91402225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist