Healthcare Provider Details

I. General information

NPI: 1184249609
Provider Name (Legal Business Name): MANUEL R PERALTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

544 BLUE MOUNTAIN RISE
CANTON GA
30114-5713
US

IV. Provider business mailing address

544 BLUE MOUNTAIN RISE
CANTON GA
30114-5713
US

V. Phone/Fax

Practice location:
  • Phone: 718-310-9851
  • Fax: 718-310-9851
Mailing address:
  • Phone:
  • Fax: 718-310-9851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA005366
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: