Provider Demographics
NPI:1619335544
Name:MANAGUELOD, VIC PADILA (NP)
Entity Type:Individual
Prefix:
First Name:VIC
Middle Name:PADILA
Last Name:MANAGUELOD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 E CYPRESS AVE
Mailing Address - Street 2:APT A
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-3211
Mailing Address - Country:US
Mailing Address - Phone:818-813-4208
Mailing Address - Fax:
Practice Address - Street 1:630 E CYPRESS AVE
Practice Address - Street 2:APT A
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91501-3211
Practice Address - Country:US
Practice Address - Phone:818-813-4208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-06
Last Update Date:2016-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003644363L00000X, 363LA2100X, 363LA2200X, 363LF0000X, 363LP0200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care