Healthcare Provider Details

I. General information

NPI: 1356475701
Provider Name (Legal Business Name): JETRO MANIPES TENERIFE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 ALABASTER WAY STE328
DELTONA FL
32725-4324
US

IV. Provider business mailing address

PO BOX 1975
ROME GA
30162-1975
US

V. Phone/Fax

Practice location:
  • Phone: 386-218-3833
  • Fax:
Mailing address:
  • Phone: 706-204-8548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 22707
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: