Provider Demographics
NPI:1205281862
Name:MANDRAN HEALTH PLLC
Entity type:Organization
Organization Name:MANDRAN HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:H
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-275-0035
Mailing Address - Street 1:4010 DUPONT CIR STE 411
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4837
Mailing Address - Country:US
Mailing Address - Phone:502-275-0035
Mailing Address - Fax:502-275-0034
Practice Address - Street 1:4010 DUPONT CIR STE 411
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4837
Practice Address - Country:US
Practice Address - Phone:502-275-0035
Practice Address - Fax:502-275-0034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty