MEDICARE: MR. RANDOLPH J MANN PT

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	598	AZ

General Provider Information

NPI Number	:	1356478770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDOLPH J MANN PT

Provider Business Mailing Address
First Line	:	PO BOX 5189
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85312-5189
Country	:	US
Telephone Number	:	623-875-4440
Fax Number	:	623-773-9472

Provider Business Practice Location Address
First Line	:	9885 W UNION HILLS
Second Line	:	SUITE 100
City	:	SUN CITY
State	:	AZ
Zip	:	85373-1705
Country	:	US
Telephone Number	:	623-875-4440
Fax Number	:	623-773-9472

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	07/08/2007

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