MEDICARE: MANIKANDAN ELLANGOVIN MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501014992	MI

General Provider Information

NPI Number	:	1093203143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANIKANDAN ELLANGOVIN MPT

Provider Business Mailing Address
First Line	:	6052 AMBER LN
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-7820
Country	:	US
Telephone Number	:	810-410-6663
Fax Number	:

Provider Business Practice Location Address
First Line	:	6052 AMBER LN
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-7820
Country	:	US
Telephone Number	:	810-410-6663
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2018
Last Update Date	:	04/24/2018

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