Basic Information
| Provider Information | |||||||||
| NPI: | 1164752564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAMMEN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | VARGHESE | ||||||||
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| OtherLastName: | VARGHESE | ||||||||
| OtherFirstName: | SUSAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22 ODYSSEY | ||||||||
| Address2: | #165 | ||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926183186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497272192 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22 ODYSSEY | ||||||||
| Address2: | #165 | ||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926183186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497272192 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2010 | ||||||||
| LastUpdateDate: | 05/19/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 36259 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 62-027654 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.