Healthcare Provider Details

I. General information

NPI: 1497902977
Provider Name (Legal Business Name): CAROLE CAMPBELL MANGE AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 03/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

5105 LENOX AVE
SAINT LOUIS MO
63119-4343
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5671
  • Fax:
Mailing address:
  • Phone: 314-647-4730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number01958
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: