Provider Demographics
NPI:1235321563
Name:JENISE M. MANCINI O.D., P.C.
Entity Type:Organization
Organization Name:JENISE M. MANCINI O.D., P.C.
Other - Org Name:DR. JENISE KOZIOL MANCINI
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-851-7178
Mailing Address - Street 1:45 DOC STONE RD
Mailing Address - Street 2:101
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-4555
Mailing Address - Country:US
Mailing Address - Phone:540-720-2020
Mailing Address - Fax:540-288-2020
Practice Address - Street 1:45 DOC STONE RD
Practice Address - Street 2:101
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-4555
Practice Address - Country:US
Practice Address - Phone:540-720-2020
Practice Address - Fax:540-288-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1463152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA410000609Medicare PIN