Provider Demographics
NPI:1366855033
Name:MANCILLA, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:MANCILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 FLORENTINA AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-4214
Mailing Address - Country:US
Mailing Address - Phone:323-314-9344
Mailing Address - Fax:
Practice Address - Street 1:10428 LOWER AZUSA RD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-1208
Practice Address - Country:US
Practice Address - Phone:626-652-0755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner