Provider Demographics
NPI:1144391392
Name:LANGENBACH, MARK RICHARD (PT, MBA, OCS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RICHARD
Last Name:LANGENBACH
Suffix:
Gender:M
Credentials:PT, MBA, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13055 W MCDOWELL RD
Mailing Address - Street 2:SUITE G-107
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-6449
Mailing Address - Country:US
Mailing Address - Phone:623-547-4787
Mailing Address - Fax:
Practice Address - Street 1:13055 W MCDOWELL RD
Practice Address - Street 2:SUITE G-107
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-6449
Practice Address - Country:US
Practice Address - Phone:623-547-4787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
107735Medicare PIN
Z63124Medicare PIN