Healthcare Provider Details

I. General information

NPI: 1780800250
Provider Name (Legal Business Name): EDWARD MACANGA JR. DM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 FRONT ST
BEREA OH
44017-1943
US

IV. Provider business mailing address

255 FRONT ST
BEREA OH
44017-1943
US

V. Phone/Fax

Practice location:
  • Phone: 440-826-1440
  • Fax:
Mailing address:
  • Phone: 440-826-1440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number3639
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: