Provider Demographics
NPI:1669520318
Name:MANGAT MEDICAL LLC
Entity type:Organization
Organization Name:MANGAT MEDICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:BRIGHT
Authorized Official - Last Name:RUE
Authorized Official - Suffix:III
Authorized Official - Credentials:RN, MBA, CHE, CASC
Authorized Official - Phone:859-426-1616
Mailing Address - Street 1:133 BARNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2500
Mailing Address - Country:US
Mailing Address - Phone:859-426-1616
Mailing Address - Fax:859-578-3321
Practice Address - Street 1:133 BARNWOOD DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-2500
Practice Address - Country:US
Practice Address - Phone:859-426-1616
Practice Address - Fax:859-578-3321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY300163261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY300163OtherASC LICENSE
69897OtherAAAHC
KY300163OtherASC LICENSE