Provider Demographics
NPI:1689275786
Name:MANTONG, MICHAEL R
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:MANTONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16152 BEACH BLVD STE 279
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3825
Mailing Address - Country:US
Mailing Address - Phone:714-509-1880
Mailing Address - Fax:424-222-8882
Practice Address - Street 1:16152 BEACH BLVD STE 279
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3825
Practice Address - Country:US
Practice Address - Phone:714-509-1880
Practice Address - Fax:424-222-8882
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304700305374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide