Provider Demographics
NPI:1225678311
Name:BANCAYANVEGA, GINO (NMD)
Entity type:Individual
Prefix:
First Name:GINO
Middle Name:
Last Name:BANCAYANVEGA
Suffix:
Gender:M
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18433 ROSCOE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-4126
Mailing Address - Country:US
Mailing Address - Phone:818-734-7620
Mailing Address - Fax:
Practice Address - Street 1:18433 ROSCOE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4126
Practice Address - Country:US
Practice Address - Phone:818-734-7620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath