Healthcare Provider Details

I. General information

NPI: 1881446185
Provider Name (Legal Business Name): NALLELY RUBI MORALES MANCILLAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 ASHLEY AVE
CHARLESTON SC
29425-8908
US

IV. Provider business mailing address

167 ASHLEY AVE
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-8289
  • Fax:
Mailing address:
  • Phone: 843-792-8289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number49202
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician
License NumberAL92926
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: