Provider Demographics
NPI:1962756049
Name:MANGULABNAN, FREIDRICH (PT, CLT)
Entity type:Individual
Prefix:
First Name:FREIDRICH
Middle Name:
Last Name:MANGULABNAN
Suffix:
Gender:M
Credentials:PT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 2ND ST
Mailing Address - Street 2:APT. 7
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-3991
Mailing Address - Country:US
Mailing Address - Phone:606-213-7248
Mailing Address - Fax:
Practice Address - Street 1:240 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:WHITESBURG
Practice Address - State:KY
Practice Address - Zip Code:41858-7627
Practice Address - Country:US
Practice Address - Phone:606-633-3524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5152225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist