Basic Information
| Provider Information | |||||||||
| NPI: | 1811661762 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANGANO | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | MS, RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 586 S ELM ST | ||||||||
| Address2: | |||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934203775 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 E CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934545906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057393000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2021 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86173948 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.