Provider Demographics
NPI:1427244060
Name:MANUEL MASAGANDA FERRERAS
Entity type:Organization
Organization Name:MANUEL MASAGANDA FERRERAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:MASAGANDA
Authorized Official - Last Name:FERRERAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-663-7511
Mailing Address - Street 1:1131 N VERMONT AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029
Mailing Address - Country:US
Mailing Address - Phone:328-663-7511
Mailing Address - Fax:323-663-1104
Practice Address - Street 1:1131 N VERMONT AVE STE 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029
Practice Address - Country:US
Practice Address - Phone:328-663-7511
Practice Address - Fax:323-663-1104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL 1432 - 02-10-1988156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX003704FMedicaid