Provider Demographics
NPI:1417174392
Name:MANGUM, KEVIN DEE I (ATC LAT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DEE
Last Name:MANGUM
Suffix:I
Gender:M
Credentials:ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5325 COCOS PLUMOSAS DR
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2320
Mailing Address - Country:US
Mailing Address - Phone:504-885-9111
Mailing Address - Fax:504-731-1805
Practice Address - Street 1:5800 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70003-3876
Practice Address - Country:US
Practice Address - Phone:504-733-0255
Practice Address - Fax:504-731-1805
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAATH.J000342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer