1174392617 NPI number — MR. CONSTANCIO G BUMANGLAG JR. PBT, ASCP

Table of content: MR. CONSTANCIO G BUMANGLAG JR. PBT, ASCP (NPI 1174392617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174392617 NPI number — MR. CONSTANCIO G BUMANGLAG JR. PBT, ASCP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUMANGLAG
Provider First Name:
CONSTANCIO
Provider Middle Name:
G
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
PBT, ASCP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174392617
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
91 1001 KEAUNUI DRIVE
Provider Second Line Business Mailing Address:
215
Provider Business Mailing Address City Name:
EWA BEACH
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-393-8073
Provider Business Mailing Address Fax Number:
808-517-5173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
91 1001 KEAUNUI DRIVE
Provider Second Line Business Practice Location Address:
215
Provider Business Practice Location Address City Name:
EWA BEACH
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-393-8073
Provider Business Practice Location Address Fax Number:
808-517-5173
Provider Enumeration Date:
12/26/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 246RP1900X , with the licence number:  68986 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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