Provider Demographics
NPI:1306956024
Name:MANNIX, KEVIN (PT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MANNIX
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 N GRANDVIEW AVE STE A
Mailing Address - Street 2:SUITE A
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-6953
Mailing Address - Country:US
Mailing Address - Phone:432-934-5609
Mailing Address - Fax:
Practice Address - Street 1:2760 N GRANDVIEW AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-6953
Practice Address - Country:US
Practice Address - Phone:432-934-5609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1131381OtherLICENSE #
TX1131381OtherLICENSE #