MEDICARE: MR. JAMES MICHAEL MANANSALA HERNANDEZ PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	40QA01727300	NJ

General Provider Information

NPI Number	:	1356870489
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES MICHAEL MANANSALA HERNANDEZ PT

Provider Business Mailing Address
First Line	:	125 KIPP AVE
Second Line	:
City	:	LODI
State	:	NJ
Zip	:	07644-3037
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 KIPP AVE
Second Line	:
City	:	LODI
State	:	NJ
Zip	:	07644-3037
Country	:	US
Telephone Number	:	201-398-6195
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2017
Last Update Date	:	06/12/2017

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Directions to “ MR. JAMES MICHAEL MANANSALA HERNANDEZ PT” Practice Location

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