=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053538256
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARL J MANGIONE PT,DPT,OSC,RKC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 07/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1243 EASTON RD SUITE 104
-----------------------------------------------------
City | WARRINGTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18976-3801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-343-9400
-----------------------------------------------------
Fax | 215-343-4401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1243 EASTON RD SUITE 104
-----------------------------------------------------
City | WARRINGTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18976-3801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-343-9400
-----------------------------------------------------
Fax | 215-343-4401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | DAPT 000136
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------