Provider Demographics
NPI:1356475701
Name:TENERIFE, JETRO MANIPES (PT)
Entity type:Individual
Prefix:
First Name:JETRO
Middle Name:MANIPES
Last Name:TENERIFE
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:PO BOX 1975
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-1975
Mailing Address - Country:US
Mailing Address - Phone:706-204-8548
Mailing Address - Fax:
Practice Address - Street 1:1001 ALABASTER WAY
Practice Address - Street 2:STE328
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-4324
Practice Address - Country:US
Practice Address - Phone:386-218-3833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 22707225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHX315ZMedicare PIN
FLHX315YMedicare PIN