Provider Demographics
NPI:1376140590
Name:MANCILLA, LEON SAMUEL
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:SAMUEL
Last Name:MANCILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LEON
Other - Middle Name:SAMUEL
Other - Last Name:LOEB-MANCILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5555 RESERVOIR DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5134
Mailing Address - Country:US
Mailing Address - Phone:619-822-1800
Mailing Address - Fax:
Practice Address - Street 1:5555 RESERVOIR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5134
Practice Address - Country:US
Practice Address - Phone:619-822-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist