=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972664654
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANGANO CHIROPRACTIC AND WELLNESS CENTER, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6477 COLLEGE PARK SQ SUITE 216
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23464-3611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-313-2355
-----------------------------------------------------
Fax | 757-313-2357
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6477 COLLEGE PARK SQ SUITE 216
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23464-3611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-313-2355
-----------------------------------------------------
Fax | 757-313-2357
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TRISHA LYNN MANGANO
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 757-313-2355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0104001485
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------