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NPI Code Detail

MEDICARE: MR. JESUS MANCILLA SR. RSA

MEDICARE: MR. JESUS MANCILLA SR. RSA
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
1174400000XSpecialistIL

General Provider Information

NPI Number : 1205965050
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JESUS MANCILLA SR. RSA
Provider Business Mailing Address
First Line : 8021 42ND CT
Second Line :
City : LYONS
State : IL
Zip : 60534-1165
Country : US
Telephone Number : 708-442-1172
Fax Number :
Provider Business Practice Location Address
First Line : 3538 W FULLERTON AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60647-2443
Country : US
Telephone Number : 773-772-1212
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/05/2007
Last Update Date : 07/08/2007

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