1174982821 NPI number — MAURIANA D MANALO DPT

Table of content: MAURIANA D MANALO DPT (NPI 1174982821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174982821 NPI number — MAURIANA D MANALO DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANALO
Provider First Name:
MAURIANA
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILCOX
Provider Other First Name:
MAURIANA
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174982821
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1800 HARRISON ST FL 7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94612-3466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-625-2856
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6600 BRUCEVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95823-4671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-688-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2016

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: 225100000X , with the licence number:  291156 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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