=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285118067
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANUAL MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2018
-----------------------------------------------------
Last Update Date | 04/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 89 N MAIN ST
-----------------------------------------------------
City | POLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44514-1693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-774-3464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 89 N MAIN ST
-----------------------------------------------------
City | POLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44514-1693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-423-2464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HOME HEALTH/PERFORMANCE ENHANCEMENT
-----------------------------------------------------
Name | DR. DAVID DENTON
-----------------------------------------------------
Credential | PT, DPT, CIDN, CVT
-----------------------------------------------------
Telephone | 330-774-3464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------