Basic Information
| Provider Information | |||||||||
| NPI: | 1770879124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAHNENSMITH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | REX | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT, DPT, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 CENTERVILLE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028864376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017376011 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 535 CENTERVILLE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028864376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017376011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2011 | ||||||||
| LastUpdateDate: | 06/13/2016 | ||||||||
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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 | 225100000X | 0400090284 | VT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305206947 | VA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 3680 | NH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT02905 | RI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.