Provider Demographics
NPI:1760936090
Name:MANCO, GENTI
Entity Type:Individual
Prefix:
First Name:GENTI
Middle Name:
Last Name:MANCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 22ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1563
Mailing Address - Country:US
Mailing Address - Phone:630-573-5000
Mailing Address - Fax:
Practice Address - Street 1:1 ERIE CT
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2566
Practice Address - Country:US
Practice Address - Phone:708-524-4576
Practice Address - Fax:708-524-0573
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-03
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014660363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily