Provider Demographics
NPI:1225678311
Name:BANCAYANVEGA, GINO (ND, CNS, LDN)
Entity type:Individual
Prefix:DR
First Name:GINO
Middle Name:
Last Name:BANCAYANVEGA
Suffix:
Gender:M
Credentials:ND, CNS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 E BUENA VISTA STREET
Mailing Address - Street 2:
Mailing Address - City:KANSAS
Mailing Address - State:IL
Mailing Address - Zip Code:61933
Mailing Address - Country:US
Mailing Address - Phone:619-721-2550
Mailing Address - Fax:
Practice Address - Street 1:137 E BUENA VISTA STREET
Practice Address - Street 2:
Practice Address - City:KANSAS
Practice Address - State:IL
Practice Address - Zip Code:61933
Practice Address - Country:US
Practice Address - Phone:619-721-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175F00000X
IL164.022503133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No133N00000XDietary & Nutritional Service ProvidersNutritionist