1912582289 NPI number — JOSE LUIS MANCILLA JR.

Table of content: JOSE LUIS MANCILLA JR. (NPI 1912582289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912582289 NPI number — JOSE LUIS MANCILLA JR.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANCILLA
Provider First Name:
JOSE
Provider Middle Name:
LUIS
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912582289
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
750 N COMMONS DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60504-7940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-303-5380
Provider Business Mailing Address Fax Number:
630-303-5385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30250 RANCHO VIEJO RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JUAN CAPISTRANO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92675-1555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-489-0668
Provider Business Practice Location Address Fax Number:
949-489-1475
Provider Enumeration Date:
03/17/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  7903 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7903 . This is a "HEARING INSTRUMENT SPECIALIST" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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