Healthcare Provider Details

I. General information

NPI: 1598672560
Provider Name (Legal Business Name): KAILEN MANGU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 S ARCHIBALD AVE STE C-2
ONTARIO CA
91761-9007
US

IV. Provider business mailing address

3055 S ARCHIBALD AVE STE C-2
ONTARIO CA
91761-9007
US

V. Phone/Fax

Practice location:
  • Phone: 909-460-6487
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310380
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: