Healthcare Provider Details

I. General information

NPI: 1548622053
Provider Name (Legal Business Name): DR. WESTON R MANGOLD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 N BECHTLE AVE
SPRINGFIELD OH
45504-1583
US

IV. Provider business mailing address

7152 QUARTERHORSE DR
SPRINGBORO OH
45066-7784
US

V. Phone/Fax

Practice location:
  • Phone: 937-399-8000
  • 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 R MANGOLD
Title or Position: OWNER
Credential: O.D.
Phone: 937-399-8000