Provider Demographics
NPI:1033991443
Name:MANGOSTANA LLC
Entity Type:Organization
Organization Name:MANGOSTANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:505-221-6475
Mailing Address - Street 1:6804 KELLY ANN RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3769
Mailing Address - Country:US
Mailing Address - Phone:505-221-6475
Mailing Address - Fax:
Practice Address - Street 1:1020 COAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-5206
Practice Address - Country:US
Practice Address - Phone:505-221-6475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty