Healthcare Provider Details

I. General information

NPI: 1043147457
Provider Name (Legal Business Name): MARIVIC MANLULU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 COFFEE RD
MODESTO CA
95355-2803
US

IV. Provider business mailing address

1700 COFFEE RD
MODESTO CA
95355-2803
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-4500
  • Fax: 209-569-7328
Mailing address:
  • Phone: 209-526-4500
  • Fax: 209-569-7328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number462788
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: