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General NPI Number Information
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NPI Number | 1962065516
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Entity Type | Individual
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Provider Name | JORGE MANTILLA SA-C
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Gender | Male
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Dates
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Enumeration Date | 04/18/2019
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Last Update Date | 02/11/2020
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Provider Practice Location Address
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Address Line | 5540 N KIMBALL AVE APT 3E
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City | CHICAGO
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State | IL
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Zip | 60625-4674
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Country | US
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Telephone | 312-983-0540
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Fax |
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Provider Business Mailing Address
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Address Line | 5540 N KIMBALL AVE APT 3E
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City | CHICAGO
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State | IL
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Zip | 60625-4674
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Country | US
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Telephone | 312-983-0540
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | 19-180
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 238.000655
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License Number State | IL
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