Provider Demographics
NPI:1639853633
Name:DI MANGO, TIM ANGELO (MA, ATC, LAT)
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:ANGELO
Last Name:DI MANGO
Suffix:
Gender:M
Credentials:MA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4512 N SAGINAW RD APT 207
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-2004
Mailing Address - Country:US
Mailing Address - Phone:248-760-3028
Mailing Address - Fax:
Practice Address - Street 1:4000 WHITING DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2398
Practice Address - Country:US
Practice Address - Phone:248-760-3028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010026362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer