1316992548 NPI number — MR. BRAD A MANGUM P.T.

Table of content: CHIMANMA WILLIAMS (NPI 1710731633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316992548 NPI number — MR. BRAD A MANGUM P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANGUM
Provider First Name:
BRAD
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316992548
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1055 N 500 W ATTN: CREDENTIALING
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-354-8225
Provider Business Mailing Address Fax Number:
801-418-0941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 WEST SR 164
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
385-203-1313
Provider Business Practice Location Address Fax Number:
801-429-0629
Provider Enumeration Date:
05/24/2006

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:  5003636-2401 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50036362401001 . This is a "BCBS PPO" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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