Provider Demographics
NPI:1952389835
Name:MANALO, LADY EINETTE MEDINA
Entity type:Individual
Prefix:
First Name:LADY EINETTE
Middle Name:MEDINA
Last Name:MANALO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 E. LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805
Mailing Address - Country:US
Mailing Address - Phone:714-635-2642
Mailing Address - Fax:
Practice Address - Street 1:1717 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-4345
Practice Address - Country:US
Practice Address - Phone:714-956-0803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-02
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27987225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist