Provider Demographics
NPI:1639710296
Name:VILLALTA, NELSON MANRIQUE (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:MANRIQUE
Last Name:VILLALTA
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6529 SEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4208
Mailing Address - Country:US
Mailing Address - Phone:323-582-5770
Mailing Address - Fax:
Practice Address - Street 1:6529 SEVILLE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4208
Practice Address - Country:US
Practice Address - Phone:323-582-5770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician