Provider Demographics
NPI:1689159964
Name:VELAGANDULA, MANOJ KUMAR
Entity Type:Individual
Prefix:
First Name:MANOJ KUMAR
Middle Name:
Last Name:VELAGANDULA
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 1:2271 SHORE HILL DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1967
Mailing Address - Country:US
Mailing Address - Phone:408-718-3732
Mailing Address - Fax:
Practice Address - Street 1:2271 SHORE HILL DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-1967
Practice Address - Country:US
Practice Address - Phone:408-718-3732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005213225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant