Healthcare Provider Details

I. General information

NPI: 1669520318
Provider Name (Legal Business Name): MANGAT MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BARNWOOD DR
EDGEWOOD KY
41017-2500
US

IV. Provider business mailing address

133 BARNWOOD DR
EDGEWOOD KY
41017-2500
US

V. Phone/Fax

Practice location:
  • Phone: 859-426-1616
  • Fax: 859-578-3321
Mailing address:
  • Phone: 859-426-1616
  • Fax: 859-578-3321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number300163
License Number StateKY

VIII. Authorized Official

Name: MR. NELSON BRIGHT RUE III
Title or Position: EXECUTIVE DIRECTOR
Credential: RN, MBA, CHE, CASC
Phone: 859-426-1616