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NPI Code Detail

MEDICARE: ELENITA MANDILAG CARLSON P.T.

MEDICARE: ELENITA MANDILAG CARLSON P.T.
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
1225100000XPhysical Therapist5501013549MI

General Provider Information

NPI Number : 1336646819
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELENITA MANDILAG CARLSON P.T.
Provider Business Mailing Address
First Line : 14745 MERCURY DR
Second Line :
City : GRAND HAVEN
State : MI
Zip : 49417-9703
Country : US
Telephone Number : 973-960-1216
Fax Number :
Provider Business Practice Location Address
First Line : 900 S BEACON BLVD
Second Line :
City : GRAND HAVEN
State : MI
Zip : 49417-2146
Country : US
Telephone Number : 616-846-1850
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/10/2018
Last Update Date : 04/10/2018

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