Healthcare Provider Details

I. General information

NPI: 1851156137
Provider Name (Legal Business Name): KARINA BANDA-MANCILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2024
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16044 COUNTY ROAD 165
TYLER TX
75703-7302
US

IV. Provider business mailing address

19081 GREENLEAF DR
FLINT TX
75762-9527
US

V. Phone/Fax

Practice location:
  • Phone: 903-526-5599
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2163185
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: