Healthcare Provider Details

I. General information

NPI: 1669279287
Provider Name (Legal Business Name): TYRONE MANGUM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2025
Last Update Date: 03/01/2025
Certification Date: 03/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7136 TANGER BLVD
RIVERDALE GA
30296-6072
US

IV. Provider business mailing address

7136 TANGER BLVD
RIVERDALE GA
30296-6072
US

V. Phone/Fax

Practice location:
  • Phone: 919-812-8441
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: