=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104442581
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIDGETTE MANGOLD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2020
-----------------------------------------------------
Last Update Date | 06/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9368 CEDAR CENTER WAY
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40291-4522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-231-3979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6417 COLOME DR
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40291-2976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-221-9113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | TP2020003
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------