Provider Demographics
NPI:1982004115
Name:MANGULABNAN, MARC
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:MANGULABNAN
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 1:558 HIGHWAY 35
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-5066
Mailing Address - Country:US
Mailing Address - Phone:732-219-5700
Mailing Address - Fax:732-219-5703
Practice Address - Street 1:528 NEW FRIENDSHIP RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:NJ
Practice Address - Zip Code:07731-2978
Practice Address - Country:US
Practice Address - Phone:732-901-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01570500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist