Provider Demographics
NPI:1669840880
Name:MANDAC, MIGUEL
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:MANDAC
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 1:13128 TOTEM LAKE BLVD NE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-2953
Mailing Address - Country:US
Mailing Address - Phone:425-820-8837
Mailing Address - Fax:
Practice Address - Street 1:13128 TOTEM LAKE BLVD NE
Practice Address - Street 2:SUITE 203
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2953
Practice Address - Country:US
Practice Address - Phone:425-820-8837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60485024225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist