MEDICARE: MARDI EDEN MANGUS DPT

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	PT38833	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT38833	OTHER	FL	FLORIDA DEPARTMENT OF HEALTH

General Provider Information

NPI Number	:	1144955584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARDI EDEN MANGUS DPT

Provider Business Mailing Address
First Line	:	309 RUNAWAY CIR
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-1255
Country	:	US
Telephone Number	:	716-860-8021
Fax Number	:

Provider Business Practice Location Address
First Line	:	708 3RD ST N
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-7149
Country	:	US
Telephone Number	:	904-822-4622
Fax Number	:

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

Provider Enumeration Date	:	07/20/2022
Last Update Date	:	07/20/2022

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Directions to “ MARDI EDEN MANGUS DPT” Practice Location

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