Provider Demographics
NPI:1194185439
Name:MANGULABNAN, WARREN C (RPT)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:C
Last Name:MANGULABNAN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28720 BAYBERRY CT W
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-3867
Mailing Address - Country:US
Mailing Address - Phone:248-396-9193
Mailing Address - Fax:313-741-1171
Practice Address - Street 1:33620 FIVE MILE RD STE A
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-2866
Practice Address - Country:US
Practice Address - Phone:248-957-8930
Practice Address - Fax:313-541-1171
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009909174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501009909OtherPHYSICAL THERAPY LICENSE