Provider Demographics
NPI:1649662800
Name:MANUEL, ROLANDO E JR
Entity type:Individual
Prefix:
First Name:ROLANDO
Middle Name:E
Last Name:MANUEL
Suffix:JR
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 1:519 SOUTHSHORE LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-4100
Mailing Address - Country:US
Mailing Address - Phone:770-639-3547
Mailing Address - Fax:
Practice Address - Street 1:519 SOUTHSHORE LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-4100
Practice Address - Country:US
Practice Address - Phone:770-639-3547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA001792225100000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant