Provider Demographics
NPI:1740992858
Name:MANGA, KAMDEM JAMES
Entity type:Individual
Prefix:
First Name:KAMDEM
Middle Name:JAMES
Last Name:MANGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 RIDGELAND OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76120-1745
Mailing Address - Country:US
Mailing Address - Phone:240-646-4794
Mailing Address - Fax:
Practice Address - Street 1:1910 PACIFIC AVE STE 11500
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-4559
Practice Address - Country:US
Practice Address - Phone:240-646-4794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities