Basic Information
| Provider Information | |||||||||
| NPI: | 1639624075 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MANGABAT | ||||||||
| FirstName: | MAX | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15410 S MOUNTAIN PKWY | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850446691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807061161 | ||||||||
| FaxNumber: | 4807067997 | ||||||||
| Practice Location | |||||||||
| Address1: | 13967 W GRAND AVE | ||||||||
| Address2: | SUITE C-100 | ||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853743732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234743952 | ||||||||
| FaxNumber: | 6234743953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2016 | ||||||||
| LastUpdateDate: | 08/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251S0007X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 225100000X | 12397 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.