Healthcare Provider Details

I. General information

NPI: 1962065516
Provider Name (Legal Business Name): JORGE MANTILLA SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5540 N KIMBALL AVE APT 3E
CHICAGO IL
60625-4674
US

IV. Provider business mailing address

5540 N KIMBALL AVE APT 3E
CHICAGO IL
60625-4674
US

V. Phone/Fax

Practice location:
  • Phone: 312-983-0540
  • Fax:
Mailing address:
  • Phone: 312-983-0540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number238.000655
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number19-180
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: