Healthcare Provider Details

I. General information

NPI: 1568808053
Provider Name (Legal Business Name): MANGA HEALTH CONSULTANTS, DBA / REGIONAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2013
Last Update Date: 05/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 PATHVIEW CT
DACULA GA
30019-7849
US

IV. Provider business mailing address

699 PATHVIEW CT
DACULA GA
30019-7849
US

V. Phone/Fax

Practice location:
  • Phone: 770-237-8835
  • Fax: 770-237-8833
Mailing address:
  • Phone: 770-237-8835
  • Fax: 770-237-8833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number067-R-0854
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number37
License Number StateGA

VIII. Authorized Official

Name: MRS. MERCY BOH MANGA
Title or Position: DIRECTOR OF NURSING
Credential: APRN, MSN
Phone: 678-863-2342