MEDICARE: MISS LENORE ODESSA MANGASER R.D.

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	133V00000X	Registered Dietitian	007003-1	NY

General Provider Information

NPI Number	:	1942576491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS LENORE ODESSA MANGASER R.D.

Provider Business Mailing Address
First Line	:	PO BOX 13642
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19101-3642
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	280 MARIN BLVD APT 21F
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07302-3689
Country	:	US
Telephone Number	:	646-265-1162
Fax Number	:

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

Provider Enumeration Date	:	03/29/2012
Last Update Date	:	08/21/2024

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