Provider Demographics
NPI:1336627066
Name:MANZO, OMAR (COTA)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:MANZO
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7516 N 2ND LN
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-5682
Mailing Address - Country:US
Mailing Address - Phone:956-525-2020
Mailing Address - Fax:956-682-6536
Practice Address - Street 1:7516 N 2ND LN
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504
Practice Address - Country:US
Practice Address - Phone:956-525-2020
Practice Address - Fax:956-682-6536
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209791224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty