Healthcare Provider Details

I. General information

NPI: 1356182810
Provider Name (Legal Business Name): RYAN REGINEEL MANGAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 06/06/2024
Certification Date: 06/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 RIVER PL W
FRESNO CA
93720
US

IV. Provider business mailing address

3978 VISTA GRANDE DR
SAN DIEGO CA
92115-6734
US

V. Phone/Fax

Practice location:
  • Phone: 559-256-4968
  • Fax:
Mailing address:
  • Phone: 209-918-9885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: