Provider Demographics
NPI:1699714287
Name:MANGUNSONG, VICTORIA (PT)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:MANGUNSONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26609 HUMMINGBIRD CT
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6747
Mailing Address - Country:US
Mailing Address - Phone:909-796-8400
Mailing Address - Fax:909-796-8444
Practice Address - Street 1:11354 MOUNTAIN VIEW AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3855
Practice Address - Country:US
Practice Address - Phone:909-796-8400
Practice Address - Fax:909-796-8444
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26565225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OPT265650Medicare ID - Type Unspecified