MEDICARE: MANGOSTANA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist
2	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1033991443
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANGOSTANA LLC

Provider Business Mailing Address
First Line	:	6804 KELLY ANN RD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-3769
Country	:	US
Telephone Number	:	505-221-6475
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 COAL AVE SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-5206
Country	:	US
Telephone Number	:	505-221-6475
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ THERAPIST
Name	:	KAREN CHAN
Credential	:	PT
Telephone Number	:	505-221-6475

Provider Enumeration Date	:	10/19/2023
Last Update Date	:	10/19/2023

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Directions to “MANGOSTANA LLC ” Practice Location

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