Provider Demographics
NPI:1912395740
Name:NANIONG, ROGELIO BAMBALAN JR
Entity Type:Individual
Prefix:MR
First Name:ROGELIO
Middle Name:BAMBALAN
Last Name:NANIONG
Suffix:JR
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 1:512 W IMPERIAL AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-2102
Mailing Address - Country:US
Mailing Address - Phone:310-598-0174
Mailing Address - Fax:
Practice Address - Street 1:3533 MOTOR AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-4806
Practice Address - Country:US
Practice Address - Phone:310-836-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-01
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9023225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant