Healthcare Provider Details

I. General information

NPI: 1922334911
Provider Name (Legal Business Name): DR WESTON R MANGOLD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2009
Last Update Date: 10/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1274 E 2ND ST
FRANKLIN OH
45005-1994
US

IV. Provider business mailing address

7152 QUARTERHORSE DR
SPRINGBORO OH
45066-7784
US

V. Phone/Fax

Practice location:
  • Phone: 937-704-0809
  • Fax:
Mailing address:
  • Phone: 937-321-1033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4122
License Number StateOH

VIII. Authorized Official

Name: DR. WESTON RAY MANGOLD
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 937-321-1033