Healthcare Provider Details

I. General information

NPI: 1801401963
Provider Name (Legal Business Name): MANUEL GAMBINO CI42710524
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MANUEL GAMBINO

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 10/31/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 EAST HARRY BRIDGES BOULEVARD
WILMINGTON CA
90744
US

IV. Provider business mailing address

117 EAST HARRY BRIDGES BOULEVARD
WILMINGTON CA
90744
US

V. Phone/Fax

Practice location:
  • Phone: 310-549-8383
  • Fax: 310-835-1202
Mailing address:
  • Phone: 310-549-8383
  • Fax: 310-835-1202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: