Provider Demographics
NPI:1124110762
Name:MANCINO, ROBERT J
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:MANCINO
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:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-0236
Mailing Address - Country:US
Mailing Address - Phone:707-994-4965
Mailing Address - Fax:707-994-4965
Practice Address - Street 1:14810 CRESTA AVE
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8188
Practice Address - Country:US
Practice Address - Phone:707-994-4965
Practice Address - Fax:707-994-4965
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHT195562471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXR000131FOtherMEDI-CAL
CAZZZ00131ZMedicare ID - Type UnspecifiedPROVIDER #