Provider Demographics
NPI:1124305255
Name:MANIMBO, CONRADO VILLASENOR
Entity type:Individual
Prefix:MR
First Name:CONRADO
Middle Name:VILLASENOR
Last Name:MANIMBO
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 1:1325 N. RED GUM ST.
Mailing Address - Street 2:SUITE 14
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806
Mailing Address - Country:US
Mailing Address - Phone:714-238-9005
Mailing Address - Fax:714-238-9085
Practice Address - Street 1:1325 N. RED GUM ST.
Practice Address - Street 2:SUITE 14
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806
Practice Address - Country:US
Practice Address - Phone:714-238-9005
Practice Address - Fax:714-238-9085
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTN01213FMedicaid