MEDICARE: DR. MARK RUSSELL MANGOLD D.C., QME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NS0005X	Sports Physician Chiropractor	DC21419	CA

General Provider Information

NPI Number	:	1134205727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK RUSSELL MANGOLD D.C., QME

Provider Business Mailing Address
First Line	:	751 S WEIR CANYON RD STE 181
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92808-1962
Country	:	US
Telephone Number	:	714-974-3930
Fax Number	:	714-974-0277

Provider Business Practice Location Address
First Line	:	751 S WEIR CANYON RD STE 181
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92808-1962
Country	:	US
Telephone Number	:	714-974-3930
Fax Number	:	714-974-0277

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	01/15/2026

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