Provider Demographics
NPI:1356478770
Name:MANN, RANDOLPH J (PT)
Entity Type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:J
Last Name:MANN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5189
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85312-5189
Mailing Address - Country:US
Mailing Address - Phone:623-875-4440
Mailing Address - Fax:623-773-9472
Practice Address - Street 1:9885 W UNION HILLS
Practice Address - Street 2:SUITE 100
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85373-1705
Practice Address - Country:US
Practice Address - Phone:623-875-4440
Practice Address - Fax:623-773-9472
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ598225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ27767Medicare ID - Type Unspecified