Provider Demographics
NPI:1023426160
Name:MANDALA, KEVIN (DPT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MANDALA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24951 NORTH CIRCLE DRIVE
Mailing Address - Street 2:NICHOL HALL, RM 1809
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-558-8108
Mailing Address - Fax:
Practice Address - Street 1:1485 S HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-3522
Practice Address - Country:US
Practice Address - Phone:435-654-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-7574225100000X
UT9161047-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist