Provider Demographics
NPI:1902511736
Name:MANGRUM HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:MANGRUM HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ADIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGRUM
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:916-317-1503
Mailing Address - Street 1:306 VIRGINIA LEE LN
Mailing Address - Street 2:
Mailing Address - City:EFLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27243-9497
Mailing Address - Country:US
Mailing Address - Phone:916-317-1503
Mailing Address - Fax:
Practice Address - Street 1:306 VIRGINIA LEE LN
Practice Address - Street 2:
Practice Address - City:EFLAND
Practice Address - State:NC
Practice Address - Zip Code:27243-9497
Practice Address - Country:US
Practice Address - Phone:916-317-1503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy