Healthcare Provider Details

I. General information

NPI: 1043129190
Provider Name (Legal Business Name): NATHAN GABRIEL MANARANG SAN FELIPE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7193 INDUSTRIAL BLVD NE
COVINGTON GA
30014-1478
US

IV. Provider business mailing address

30 KATELEN CT
COVINGTON GA
30016-7720
US

V. Phone/Fax

Practice location:
  • Phone: 770-788-8222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT010892
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: