MEDICARE: MAX MANGABAT 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	2251S0007X	Sports Physical Therapist
2	225100000X	Physical Therapist	12397	AZ
3	2251X0800X	Orthopedic Physical Therapist

General Provider Information

NPI Number	:	1639624075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAX MANGABAT DPT

Provider Business Mailing Address
First Line	:	15410 S MOUNTAIN PKWY
Second Line	:	SUITE 112
City	:	PHOENIX
State	:	AZ
Zip	:	85044-6691
Country	:	US
Telephone Number	:	480-706-1161
Fax Number	:	480-706-7997

Provider Business Practice Location Address
First Line	:	13967 W GRAND AVE
Second Line	:	SUITE C-100
City	:	SURPRISE
State	:	AZ
Zip	:	85374-3732
Country	:	US
Telephone Number	:	623-474-3952
Fax Number	:	623-474-3953

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

Provider Enumeration Date	:	08/15/2016
Last Update Date	:	08/15/2016

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Directions to “ MAX MANGABAT DPT” Practice Location

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