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General NPI Number Information
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NPI Number | 1649405564
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Entity Type | Organization
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Legal Business Name | MANGOLD CENTER FOR FAMILY HEALTH AND WELLNESS
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Dates
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Enumeration Date | 05/20/2009
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Last Update Date | 09/01/2011
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Provider Practice Location Address
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Address Line | 120 N MAIN ST #120
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City | WEST BEND
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State | WI
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Zip | 53095-3376
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Country | US
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Telephone | 262-338-8100
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Fax | 262-292-9747
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Provider Business Mailing Address
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Address Line | 120 N MAIN ST STE 120
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City | WEST BEND
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State | WI
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Zip | 53095-3360
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Country | US
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Telephone | 262-338-8100
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Fax | 262-338-0405
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. MICHAEL N MANGOLD
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Credential | MD
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Telephone | 262-338-8100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 32859
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License Number State | WI
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