Provider Demographics
NPI:1417085754
Name:MANIMBO, MARIA NELLY GANGAT
Entity Type:Individual
Prefix:
First Name:MARIA NELLY
Middle Name:GANGAT
Last Name:MANIMBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S STATE COLLEGE BLVD
Mailing Address - Street 2:# 418
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-4116
Mailing Address - Country:US
Mailing Address - Phone:714-457-1085
Mailing Address - Fax:
Practice Address - Street 1:700 S PLYMOUTH PL
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-4531
Practice Address - Country:US
Practice Address - Phone:714-457-1085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMTN01213F343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTN01213FMedicaid