Provider Demographics
NPI:1730431966
Name:TAIMANGLO, ERNIE JOHN (LAADC)
Entity type:Individual
Prefix:MR
First Name:ERNIE
Middle Name:JOHN
Last Name:TAIMANGLO
Suffix:
Gender:M
Credentials:LAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 CARLOW CT
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-2011
Mailing Address - Country:US
Mailing Address - Phone:619-750-5871
Mailing Address - Fax:
Practice Address - Street 1:338 W LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-4465
Practice Address - Country:US
Practice Address - Phone:619-255-5499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALR05710121101YA0400X
CA091760-III101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2833205OtherEIN