Healthcare Provider Details

I. General information

NPI: 1740389733
Provider Name (Legal Business Name): MELISSA R MANALO MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 WEST BALL ROAD #206
ANAHEIM CA
92804
US

IV. Provider business mailing address

3400 WEST BALL ROAD #206
ANAHEIM CA
92804
US

V. Phone/Fax

Practice location:
  • Phone: 714-826-2380
  • Fax: 714-826-2873
Mailing address:
  • Phone: 714-826-2380
  • Fax: 714-826-2873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA64278
License Number StateCA

VIII. Authorized Official

Name: MRS. MELISSA KILLO MANALO
Title or Position: PRESIDENT
Credential: MD
Phone: 714-826-2380