Healthcare Provider Details

I. General information

NPI: 1144700071
Provider Name (Legal Business Name): MANILATH VONGSAVATH RCP, RT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 ZION AVE
SAN DIEGO CA
92120-2507
US

IV. Provider business mailing address

1145 CAMINO DEL REY
CHULA VISTA CA
91910-7056
US

V. Phone/Fax

Practice location:
  • Phone: 619-528-5019
  • Fax:
Mailing address:
  • Phone: 619-621-5311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number25657
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: