Healthcare Provider Details

I. General information

NPI: 1467655779
Provider Name (Legal Business Name): TARA BETH MANCL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BRIDGE ST STE 202
DANVILLE VA
24541-1222
US

IV. Provider business mailing address

1000 OAKLAND DR
KALAMAZOO MI
49008-1282
US

V. Phone/Fax

Practice location:
  • Phone: 434-792-5964
  • Fax:
Mailing address:
  • Phone: 269-337-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301085737
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301085737
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101263573
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: