Provider Demographics
NPI:1649405564
Name:MANGOLD CENTER FOR FAMILY HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:MANGOLD CENTER FOR FAMILY HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:MANGOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-338-8100
Mailing Address - Street 1:120 N MAIN ST STE 120
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-3360
Mailing Address - Country:US
Mailing Address - Phone:262-338-8100
Mailing Address - Fax:262-338-0405
Practice Address - Street 1:120 N MAIN ST
Practice Address - Street 2:#120
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3376
Practice Address - Country:US
Practice Address - Phone:262-338-8100
Practice Address - Fax:262-292-9747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32859208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty