1295576783 NPI number — AMANDA MAMBOURG PHYSICAL THERAPIST

Table of content: AMANDA MAMBOURG PHYSICAL THERAPIST (NPI 1295576783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295576783 NPI number — AMANDA MAMBOURG PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAMBOURG
Provider First Name:
AMANDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARTMAN
Provider Other First Name:
AMANDA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHYSICAL THERAPIST
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295576783
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5995 WILCOX PL STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43016-9267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-689-2103
Provider Business Mailing Address Fax Number:
614-689-2105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5995 WILCOX PL STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43016-9267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-689-2103
Provider Business Practice Location Address Fax Number:
614-689-2105
Provider Enumeration Date:
06/06/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  013051 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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