Provider Demographics
NPI:1821341512
Name:MANGELSDORF, RONALD (CSB)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:MANGELSDORF
Suffix:
Gender:M
Credentials:CSB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4426
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-4426
Mailing Address - Country:US
Mailing Address - Phone:907-746-3236
Mailing Address - Fax:
Practice Address - Street 1:12189 E FENCE LINE DR
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-8119
Practice Address - Country:US
Practice Address - Phone:907-746-3236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner