Basic Information
Provider Information
NPI: 1881180289
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MANZO
FirstName: ANGELICA
MiddleName: ARACELI
NamePrefix:  
NameSuffix:  
Credential: RBT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6421 OSCAR CIR
Address2:  
City: ELK GROVE
State: CA
PostalCode: 957575984
CountryCode: US
TelephoneNumber: 9168977383
FaxNumber:  
Practice Location
Address1: 9355 E STOCKTON BLVD STE 100
Address2:  
City: ELK GROVE
State: CA
PostalCode: 956249476
CountryCode: US
TelephoneNumber: 9166831109
FaxNumber: 9166831140
Other Information
ProviderEnumerationDate: 07/09/2018
LastUpdateDate: 03/04/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000XRBT-17-45938CAY    

No ID Information.


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