Healthcare Provider Details

I. General information

NPI: 1053077354
Provider Name (Legal Business Name): JAN-BERNARD MANALANG AQUINO PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5478 WILSHIRE BLVD STE 208
LOS ANGELES CA
90036-4225
US

IV. Provider business mailing address

16121 BLACKHAWK ST
GRANADA HILLS CA
91344-7007
US

V. Phone/Fax

Practice location:
  • Phone: 323-936-7525
  • Fax:
Mailing address:
  • Phone: 818-427-6172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number301206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: