Healthcare Provider Details

I. General information

NPI: 1720394612
Provider Name (Legal Business Name): JOSE G. MANTILLA-ACEVEDO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 GARDEN OF THE GODS RD SUITE 120
COLORADO SPRINGS CO
80907-9427
US

IV. Provider business mailing address

1035 GARDEN OF THE GODS RD SUITE 120
COLORADO SPRINGS CO
80907-9427
US

V. Phone/Fax

Practice location:
  • Phone: 719-329-1000
  • Fax: 719-598-0807
Mailing address:
  • Phone: 719-329-1000
  • Fax: 719-598-0807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209008328
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041363059
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0991852-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: