Provider Demographics
NPI:1942339031
Name:MANCINI, MARIO ANTHONY (OMD, LAC)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:ANTHONY
Last Name:MANCINI
Suffix:
Gender:M
Credentials:OMD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 153316
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92195-3316
Mailing Address - Country:US
Mailing Address - Phone:619-287-4005
Mailing Address - Fax:619-287-1135
Practice Address - Street 1:3547 CAMINO DEL RIO S STE C
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4024
Practice Address - Country:US
Practice Address - Phone:619-287-4005
Practice Address - Fax:619-287-1135
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5467171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist