Healthcare Provider Details

I. General information

NPI: 1104620467
Provider Name (Legal Business Name): GABRIEL JAMES MANYAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2025
Last Update Date: 03/22/2026
Certification Date: 03/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 HOLMESTOWN RD
MYRTLE BEACH SC
29588-7837
US

IV. Provider business mailing address

406 NORLE ST
STATE COLLEGE PA
16801-6986
US

V. Phone/Fax

Practice location:
  • Phone: 843-652-8440
  • Fax:
Mailing address:
  • Phone: 724-809-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: