Provider Demographics
NPI:1760180061
Name:MANURUNG, ROLAND J
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:J
Last Name:MANURUNG
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 1:8465 CHAFFEE ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5009
Mailing Address - Country:US
Mailing Address - Phone:909-510-0586
Mailing Address - Fax:
Practice Address - Street 1:8465 CHAFFEE ST
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5009
Practice Address - Country:US
Practice Address - Phone:909-510-0586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50608225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant