Provider Demographics
NPI:1639624075
Name:MANGABAT, MAX (DPT)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:MANGABAT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15410 S MOUNTAIN PKWY
Mailing Address - Street 2:SUITE 112
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6691
Mailing Address - Country:US
Mailing Address - Phone:480-706-1161
Mailing Address - Fax:480-706-7997
Practice Address - Street 1:13967 W GRAND AVE
Practice Address - Street 2:SUITE C-100
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3732
Practice Address - Country:US
Practice Address - Phone:623-474-3952
Practice Address - Fax:623-474-3953
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
2251S0007X, 2251X0800X
AZ12397225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic