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General NPI Number Information
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NPI Number | 1912570987
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Entity Type | Organization
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Legal Business Name | MANGO WELLNESS LLC
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Dates
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Enumeration Date | 07/19/2021
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Last Update Date | 07/24/2025
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Provider Practice Location Address
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Address Line | 2801 13TH ST
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City | SAINT CLOUD
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State | FL
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Zip | 34769-4134
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Country | US
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Telephone | 407-593-2958
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Fax | 407-593-2957
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Provider Business Mailing Address
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Address Line | 2801 13TH ST
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City | SAINT CLOUD
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State | FL
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Zip | 34769-4134
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Country | US
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Telephone | 407-593-2958
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Fax | 407-593-2957
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Authorized Official
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Title or Position | OWNER/AUTHORIZED OFFICIAL
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Name | SIBY THOMAS PUTHENPURAYIL
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Credential | PHARMD
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Telephone | 407-593-2958
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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