Provider Demographics
NPI:1801256698
Name:PENA ROSALES, MANUEL DAVID (ATC, LAT)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:DAVID
Last Name:PENA ROSALES
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E 14TH ST
Mailing Address - Street 2:PMB 4503
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-6915
Mailing Address - Country:US
Mailing Address - Phone:580-279-4655
Mailing Address - Fax:
Practice Address - Street 1:1100 E 14TH ST
Practice Address - Street 2:PMB 4503
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-6915
Practice Address - Country:US
Practice Address - Phone:580-279-4655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer