Provider Demographics
NPI:1740859909
Name:MANGUM, DEDRIC MARVIN
Entity type:Individual
Prefix:
First Name:DEDRIC
Middle Name:MARVIN
Last Name:MANGUM
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 1:178 ISAAC TRL
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27574-9086
Mailing Address - Country:US
Mailing Address - Phone:336-592-3989
Mailing Address - Fax:
Practice Address - Street 1:178 ISAAC TRL
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27574-9086
Practice Address - Country:US
Practice Address - Phone:336-592-3989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)