=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285232561
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANA MOBILITY PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2020
-----------------------------------------------------
Last Update Date | 11/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1267 WILLIS ST STE 200
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96001-0400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-432-8278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 67-1185 MAMALAHOA HWY D-104 #153
-----------------------------------------------------
City | KAMUELA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96743-7505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-432-8278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/OWNER
-----------------------------------------------------
Name | JESSICA GARAKIAN
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 510-432-8278
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------