Basic Information
| Provider Information | |||||||||
| NPI: | 1639545569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE VERA | ||||||||
| FirstName: | MANUEL RONALD | ||||||||
| MiddleName: | BIANGCO | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12413 JUDSON RD STE 260 | ||||||||
| Address2: | |||||||||
| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782333262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106147953 | ||||||||
| FaxNumber: | 9566874554 | ||||||||
| Practice Location | |||||||||
| Address1: | 2140 BABCOCK RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106147953 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2015 | ||||||||
| LastUpdateDate: | 05/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1260540 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.