Provider Demographics
NPI:1790924074
Name:MANDEL, MICHAEL WILLIAM
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:MANDEL
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 1:4510 PERALTA BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-5755
Mailing Address - Country:US
Mailing Address - Phone:510-713-3202
Mailing Address - Fax:510-713-0684
Practice Address - Street 1:4510 PERALTA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-5755
Practice Address - Country:US
Practice Address - Phone:510-713-3202
Practice Address - Fax:510-713-0684
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010010AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility