Healthcare Provider Details

I. General information

NPI: 1770990855
Provider Name (Legal Business Name): KIP MANGAN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 E BIG BEAVER RD
TROY MI
48083-2006
US

IV. Provider business mailing address

29377 MAURICE CT
CHESTERFIELD MI
48047-3750
US

V. Phone/Fax

Practice location:
  • Phone: 248-720-0444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number2301010154
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: