Provider Demographics
NPI:1376953885
Name:LANG, MITCHELL JAY
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:JAY
Last Name:LANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 4TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-3229
Mailing Address - Country:US
Mailing Address - Phone:701-252-3467
Mailing Address - Fax:701-253-4318
Practice Address - Street 1:1105 4TH AVE NE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3229
Practice Address - Country:US
Practice Address - Phone:701-252-3467
Practice Address - Fax:701-253-4318
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND091-912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer